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HomeMy WebLinkAbout0056 GRANITE LANE - Health amstable ♦ � • ^T� .n.. tea- . � s -Corn monwealth of Massachusetts ,:` 3/�p,0�� W Title 5 Official Inspection F®rM Subsurface Sewage Disposal System Form - Not for Voluntary.Assessments - - 56 Granite In Property.Address. Irene Anderson Owner Owner's Name cr) information.is _ ._ _ _ . . - required for every- Barnstable Ma 02630 4/13/16 page. CitylTown .� State A Zip Code _ __Date_of Inspection,y--.- � Pam., Inspection results must be submitted on this form. Inspection-forms may-not-be altered-in-any`:_ _.. way. Please se6 completeness checklist at the end of the form. Imng out f rms A .Genera 'Ififormation filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not `�"` Michael:DiBuono •- i use the return: ='� d -. key. —""Name of Inspect6 ---- C:DiBuono Sewer and Drain reb <`v Company Name- y 8 Johns path Company Address S Yarmouth Ma • 02664 City/Town State -,--'-.—.Zip Code. . - - -- _. 50&364=9587 -_" S103522 r Te!ephone_-Number License Number s B. Certification E I certify that I have personally_inspected the sewage disposal system at this address and that the - information reported below is true, accurate and complete as of the time of the inspection..The inspection• was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority _ 4/13/16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use. at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 r> Commonwealth of Matssachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,. _ _w„ 56 Granite In 40 Property Address IrenefAnderson Ownerc"-, Owners Name information is required'for every Barnstable Ma 02630 4/13/16 page. city/Town ____ _._____..___ State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D. A) System Passes: t ® I have not found any information-which indicates that any of the-failure criteria described `.._ MR'In-310-C1'5'.303 or in'310 CMR'15.304 exisi..Any;failure criteria not evaluated are indicated below. , . x Comments: .; The system contains a 1,000 Gallon septic tank a dbox and 13 Bio Difusersi The system is operating properly with no signs of push back from the new leach field installed 2010 B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or'repair, as approved by ' the Board of Health, will pass. Check the box for"yes", "W or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. _ *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): •r °t1.. be .`fir. . .' - , . «. .. - t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection FOr Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments . °in, sysy,' 56 Granite In Property Address Irene Anderson Owner Owners Name - .. .. information is required for every Barnstable Ma 026W0 4/13/16 page. Cityrrown State Zip Code Date,of Inspection B. Certification (cont.) _- ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if, pumps/alarms are repaired: _ B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box: System will pass inspection if(with approval of Board of Health)-"' ❑, broken pipe(s) are replaced ❑ Y ❑ N. ❑ ND (Explain below): ❑< . obstruction is removed' `:--= D�:Y r ❑ N ❑ ND`(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑, The system required pumping more than 4 times:a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): - ❑ broken pipe(s) are replaced ❑- Y ❑ N ❑ ND (Explain below): El obstruction is removed ❑,Y . ❑ N ❑ ND,(Explain below): C) Further Evaluation is Required by,the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System�will pass unless Board of Health determines in accordance with 310 CIVIR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt,marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 ®fficial"Inspection Form' Subsurface Sewage Disposal System Form Not for Voluntary Assessments 56 Granite In Property Address Irene Anderson Owner Owner's Name information is required for every Barnstable Ma 02630 4/13/16 page. City/Town _. State Zip Code -Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in-a manner that,protects the public health, ` safety,an-d environment: ❑ The system has a septic tank and soil absorption-system (SAS) aridthe SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _ -❑ The system has aseptic tank and SAS and the.ISAS is within a Zone 1 of a publicwater supply. Ej ;The system has a septic tank.and;SAS and.the*SAS is within 50 feet of a private water supply well. „The system:has:a septic tank,and SAS and,the SAS-is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: w **This,system passes if the well water analysis; performed',at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria,are triggered. A copy of the analysis must be attached to this form. - 3. Other: D) System Failure Criteria Applicable to All Systems: r You must indicate "Yes" or"No'to each of"the following for all inspections: -Yes No " :' Backup of sewage into"facility..or system component due'to overloaded or El ` ® clogged SAS or cesspool ❑ ® Discharge or ponding of..effluent to the.surface of the ground or surface waters due to,an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6 below invert or available volume is less than '/2 day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title S Official Inspection Foam Subsurface Sewage Disposal System Form- Not for Voluntary Assessments - 56 Granite In Property Address--- Irene Anderson Owner Owner's.Name information is required for every Barnstable Ma 02630.. 4/13716 "page. City/Town . State Zip Code Date of Inspection .B.- Certification (cost:) y Yes No Required pumping more than 4 times in,the last.year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ..N Any portion of the SAS;cesspool or privy is-below high ground water elevation. ® Any portion'of cesspool or privy is within 100 feet of a surface water supply or tributary to a-surface water"§upply. ❑ ® Any portion of a,.cesspool or.privy-is Within a Zone 1,of a public well. . ❑= ❑ Any portion of a-cesspool:or'priuy is within 50"feet of a private water supply well.- El ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the.presence of ammonia nitrogen and nitrate'nitrogen"is equal to or less than 5 ppm, provided.that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving°a facility with a design flow of 2000gpd- 10,000gpd. F ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E), Large Systems: To be considered a large system the system must serve'a.facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either."yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of,a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply 4 the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area=`-IWPA) or a`•mapped Zone II of a publi',water'supply well r: a If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E•or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The.system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection F�®rr ' Subsurface Sewage Disposal System"Form =Not for Voluntary Assessments "r 56_Granite In _ ._.... M yr• .. Property Address Irene Anderson Owner Owner's'Name information equir for is every Barnstable ` required for eve Ma 02630 4/13/16 page. City/Town ___.______.State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes" or"no" as to each of the following: Yes - No_ ❑ ® Pumping information was provided by the owner, occupant, or Board of Health Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑, .® Have large volumes of:water been-introduced to the system'recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs`of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system'componenfs, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, ' dimensions, depth.of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided,with information on the proper maintenance of subsurface sewage disposal systems? _ The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to,Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information - Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example:110 gpd x#of bedrooms): 440 t5ins•3/13 Title 5 Official Inspection Form:Subsurface e Sewage •Disposal System Page 6 of 17 P Y 9 Commonwealth of Massachusetts Title 5 official Inspection For .Subsurface Sewage_Disposal System Form - Not for Voluntary Assessments �M 56 Granite In Property Address Irene Anderson Owner Owner's Name - information is required for every Barnstable Ma 02630" 4/13/16 . page. CitylTown State Zip Code Date of Inspection D. System-information Description: The system contains a 1,000 Gallon septic tank a dbox and 13 Bio Difusers.'The`system is operating _properly with no signs of push back from the new leach field installed 2010 Number of current residents: . 2 Does residence have a garbage grinder? .. ❑ Yes ❑ No Is laundry on a separate-sewage system? (Include laundry system-inspection ❑ Yes No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? El Yes Z No Water meter readings, if.available, last 2 ears usage d 218 Gpd 9 ( Y 9 (gP ))� Detail: Sump Pump? ❑ Yes ❑ No Last date of occupancy: Date Commercial/industrial Flow Conditions:, Type of Establishment: Design flow(based on 310 CMR 15.203): :Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft„ etc.): Grease trap present? ❑ Yes. ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal,System.-Page 7 of 17 -Commonwealth of Massachusetts W Title 5 ®fficial �Inspecti®n Form Subsurface Sewage Disposal System Form - Noffor Voluntary Assessments -56 Granite In Property Address Irene Anderson - Owner Owner's Name information is required for every Barnstable Ma 02630 4/13/16 page. _:City/Town_'_:_._ __._ --State Zip Code Date of Inspection D. System Information (cont.) ' Last date'of occupancy/use: Date Other(describe below): General Information Pumping Records: - Source of information: Tank has'neve-been pumped. ( Recommend Pumping ) Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined?. Reason for pumping: - Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and,acopy of latest inspection of the I/A system by system operator under contract Tight tank. Attach a copy of the DEP'aPProval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts W. Title 5 Official Inspection Form"' . .,.. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 56 Granite In Property Address .. Irene Anderson Owner Owner's Name information is required for every Barnstable Ma 02630*' 4%1 all 6 page. City/Town State Zip Code Date of Inspection D. System-Information-(cont.) Approximate age of all components, date installed (if known)and source of information: New leaching iri 2010 Were sewage odors detected when arriving at the.site? ❑ Yes, No Building Sewer(locate on site plan): Depth below grade: 1 feet Material of construction: ® cast iron ❑40 PVC ❑ other(explain): Distance from private water supply well or suction line: , n feet •. " . Comments (on condition of joints, venting, evidence of etc.,leakage, : ) Septic Tank(locate on site plan): Depth below grade; 6feet Material of construction: ® concrete ❑.metal ❑ fiberglass . ❑.polyethylene ❑ other(explain) 1000 I tank is metal, list age • r years Is age confirmed by.a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 t .,Y. �.•M 'J .. Commonwealth of Massachusetts Title 5 Official- Inspection Forte Subsurface--Sewage Disposal System Form.-Not for Voluntary Assessments 56.Granite In Property Address Irene Anderson Owner Owner's Name information is required for every Barnstable Ma 02630 4/13/16 page. City/-rown .-_ _._.. _State- Zip Code -- Date of-Inspection D. System Information (cont.) Septic Tank(cont.) 2411 Distance from top of sludge to bottom of outlef tee or baffle Scum thickness Distance from top of scum to top of outlet tee or baffle -42" 1" Sludge stick Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? " Tape Measure - - Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of leaking,Tees and or baffles in place at time of inspection. Grease Trap (locate on site plan): Depth below grade: feet Material of construction:- ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): . Dimensions: - Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title .5 Official Inspection .For Subsurface Sewage.Disposal System Fore -Not for Voluntary Assessments 56 Granite In Property Address Irene Anderson Owner Owner's Name information is required for every Barnstable Ma 02630"" 4113116 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tees are in place and levels are normal. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site-plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: - .gallons -.. Design Flow: gallons per day Alarm present: ❑.. Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping:_ Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Officiatl Ih'spection Form. Subsurface Sewage Disposal System Form Not for Voluntary Assessments , 56 Granite In Property Address Irene Anderson Owner Owner's Name information isequired or every Barnstable Ma 02630 4/13/16 page. cityrTown State --- Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): - - Depth-of fliquid level above outlet invert Level-and,at•normal teveI- -- Comments (note if:box is level and'distribution to�outlets equal,any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): 3 Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system'is'-a' conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments - M 56 Granite In Property Address _ Irene Anderson Owner Owner's Name information is Barnstable Ma 02630 4/13/16 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: El leaching pits "'. number: ❑ leaching chambers `number ® leaching galleries number: 13 Bio Difusers_ _ _ ❑ leaching trenches ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding,.damp soil, condition of vegetation, etc.): Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and_configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection,"F®�rrn Subsurface°Sewa"ge, Disposal System Form - Not for Voluntary Assessments 56-Granite In Property Address Irene Anderson Owner Owner's Name information is required for every Barnstable Ma 02630 4/13/16 page. Cltyrrown State------- -,Zip Code Date of Inspection D. System Information (cont.) ' —Comments (note condition of soil, signs of hy, aulicJailure, level of ponding,condition of vegetation, •Yr f �._ _ . etc.): - N.o ponding.no break out Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): r t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 f Commonwealth of Massachusetts Title 5-Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments - wM 56 Granite In Property Address Irene Anderson Owner Owner's Name information is required for every Barnstable Ma 02630 4/13116 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal,system.,.including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building,.Check one of the boxes below: ❑ hand-sketch in the area below ®. drawing attached separately t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts , Title 5 Official,Inspection, Fora Subsurface Sewage Disposal System Form - Not.for Voluntary.Assessments �1M 56 Granite In Property Address Irene Anderson. Owner Owner's Name - information is required for every Barnstable Ma .02630 4/13/16 page. Cityrrown _. .__. _. State, Zip Code Date of Inspection D. System'Information Site Exaffi:. ❑' Check-Slope - ❑ Surface water" - - �- ❑ Check cellar ❑• Shallow wells Estimated depth to high ground water: 10+ ft feet Please indicate all methods used to determine the high ground water elevation: ® Obtained.from system design plans on record If checked, date of design plan reviewed- 8/17/10Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators, installers (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: See septic plans test hole data. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 r Assessing As-Built Cards Page 1 of 2 TOWN OF BARNSTABLE LOCATION SEWAGE VILLAGE 4in IcJl ASSESSOR'S MAP&PARCEL J/G 7f—. - - . INSTALLER'S NAME&PHONE N0. . i o � o�JfnGJS�✓_ Ss�'891C SEPTIC TANK CAPACITY 4 ago C G Caste/ LEACHING FACU rrY:(typ) d.LZ a-J / (size) y7�q� GPd NO.OF BEDROOMS OWNER d PERMIT DATE: 7-29-/o COMPLIANCE DATE: Separation Distance Between the: S� Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility -Feet Private Water Supply Well and Leaching Facility(If any wells exist on " site or within 200 feet of leaching facility) Feet _ Edge of Wetland and Leaching Facility Of any wetlands exist within 300 feet of leaching facility) 74-- Feet ` FURNISHED BY J rc7 : u (1in>l http://www.town.barnstable.ma.us/Assessing/H.Mdisplay.asp?mappar=316075&seq=1 4/7/2016 Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System Fora - Not for Voluntary Assessments 56 Granite In Property Address Irene Anderson Owner Owner's Name information is required for every Barnstable Ma 02630" 4/13/16 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria-Applicable to All Systems) completed ❑ System Information—Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Town of Barnstable P# Department of.Regulatory Services r ;Public Health Division - Date- :P',.� 'I�, 20 l 200 Main Street,Hyannis MA 02601 Date Scheduled 3 B 1 Time Fee Pd. (=6 t)— t f Soil Suitability Assessment for Sewage isposal Performed By: 4 Witnessed By:+ A v i IV, - _ _ LOCATION& GENERAL INFORMATION ^ Location Address - rj (�R ii+� Owner's Name T v e"e Ait 4e r 5 0 1 �1 j{ Engineer's Name fq,� C -Address. SC s Assessor's Ma /Parcel: 3��l Z 5 tr I �y f F P � NEW CONSTRUC71ON i REPAIR Telephone# + 3 hi4 00f + Land Use �fj 1 Q1�41 Slopes(35) 47,9 Surface Stones S ,1 t . + Distances from: Open Water Body v!`f ft Possible Wet Area C D`l ft Drinking Water Well 1,604 fc - _ --�� , _ Drainage Way 1 Dv ft Property Line _ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands 3n proximity to holes) — — f TP1 ; W ><.. m t JZp . [r N r . I rP-2®.. �� I I T N J 0 Q WmN3 1e 3IL N<U<NmN W �ZZ 0 J t i Opp ❑J ❑ W0 , ~~ WW UCD ril3 r� �� t.' t'I�, (� F ZZ 0 OOW. UW Z z WOO❑O { OW 000WLLJ00 -- -2e0.00 Ft -.. 0 WmCD Parent material(geologic) 1'0� �u a Depth to Bedrock. Depth to Groundwater. Standing Water in Hole- VV0 h e Weeping from Pit Face IN D k,p Estimated Seasonal High Groundwater 5 ee ei bp-M e DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: f. e@ q t6i 0 V-(' Depth Observed standing in obs.hole: _ __ in, Depth to soil mottles: in. Depth to weeping from side of obs.hole:. in, Groundwater Adjustment ft. Index Well# Reading Date: Index Well level— Adj,factor Adj.flroundwater 1 -voi— PERCOLATION TEST osteA-Op ijo Observation Hole# ` Time at 9" Depth of Perc '`► Time at 6" Start Pre-soak Time @ Gt tl - 71me(9"•6") ' End Prc-soak ` 7 Rate MinJlnch P t o: ^Site Suitability Assessment:. Site Passed 1/ Site Failed: Additional Testing Needed(Y/N) Originah"Public Health Division 1' Observation Hole Data To Be Cotnpleted on Back----------- .0 ***If percolation test is to be conducted within 100' of wetland,you must first notify the, t -`;Barnstable Conservation Division at least one(1)week prior to beginning. -t` f! r,Q:VSEPfiCVERCFORM.DOC i DATE OF TEST: APRIL 30. 2010 S 0 I L TEST L 0 G SOIL- EVALUATOR: ` - DAVID"O. COUGHANOWR, R.S., WITNESSED BY: DAVID STANTON. HEALTH DEPT. - PERC NUMBER: 12906 NO GROUNDWATER ENCOUNTERED TEST PIT 1 - { PARENT MATERIAL: PROGLACIAL OUTWASH PERC AT 62 in - 2 MIN/INCH IN C3 _SOILS i ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER i 50.44 (INCHES) HORIZON TEXTURE (MUNSELU MOTTLING { 0-4 0 LOAM' 10 YR 2/1 'NONE FRIABLE 4-10- A - LOAMY SAND - 10 YR 4/6 NONE FRIABLE 10-30 B Y _ LOAMY MED SAND 10 YR 5/6 NONE FRIABLE 30-44, Cl MEDIUM SAND 10 YR 5/6 NONE LOOSE 44-6B C2 SILTY SAND 'I 10 YR 5/3 -NONE FIRM 44.77 66-136 C3 MEDIUM SAND 10 YR 6/4 ,NONE LOOSE 3e.94 NO TEST PIT PAARENOTUNDWATE MATERIAL- PROGLACENCOUNTEI LED—OUTWASH 2, MIN/INCH IN C3,SOILS_ _.. ELEVATION DEPTH SOIL. USDA SOIL_ SOIL COLOR SOIL. OTHER (INCHES) HORIZON TEXTURE (MUNSELU MOTTLING 50.63 0-4 0 LOAM 10 YR.2/1- NONE FRIABLE 4-12 A LOAMY SAND _ _ 10 YR-4/6 NONE FRIABLE 12-32 B LOAMY MED SAND 10 YR 5/6 NONE FRIABLE r 32-45 Cl MEDIUM SAND 10 YR 5/6 NONE LOOSE ' 45-70 C2 'SILTY SAND - 10 YR 5/3 NONE FIRM 44.60 70-136 C3 MEDIUM..SAND - 10 YR 6/4- NONE LOOSE I. 39.13 - -uepullruin -- Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consistency. Gravel) DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. onsi ten Flood Insurance Rate Man: Above 500 year flood boundary No_ Yes - Within 500 year boundary No L4 Yes Within 100 year flood boundary No V/ Yes e5..:,_..._ Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the area proposed for the soil absorption system? If not,what is the depth of naturally occurring pervious material? Certification �t7V t�R I certify that on 5 (date)I have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent wit the required training,expertise and experience described in 310 CMR 15.017. ZN OF ass � "9C ti S 4ate �I Y 2(� �� DAVID( D Signature `� �" o D. " COUGHANOWR U) d,0 1/CENSER 0 Q:\.SEvnC\PERCFORM.DOC /� FVALVP� Inspeotlron Permission 2.doc Page 1 of 1 Inspection Permission 2.doc Wright, Teresa [Teresa.Wright@town.barnstable.ma.us] Sent: Friday, February 04,2011 12:00 PM To: Anderson,Irene(Nebh) Rental inspection date Monday February 7th @ loam with Bernie Klotz and Health Inspector James Parziale @ 56 Granite Lane Barnstable Teresa/508-862-4072 Date To Whom It May Concern: I, Z&Y1,^fe 4_ ,voluntarily grant permission to the Town ' (Occupants name) of Barnstable Board of Health(Agent or Health Inspector)to inspect my dwelling unit 4 `t �'� �r4� � located at �- ���-�J�C.�� �� in accordance, (House#,[Apt\Unit#if applicable],street,village) with the Town of Barnstable Code(Chapters 59 and 170)and the State Sanitary Code (105 CUR 410.000),on I hereby authorize.and name (Date of inspection) 13<- /'l©7L2 to be my tenant representative for the (Occupant representative) r purpose of this inspection. is an adult person (Occupant representative) designated and duly.authorized to act on my behalf and will be,accompanying the Town of Barnstable Board of Health for the inspection, granting access to any and all locations (including bedrooms,bathrooms,closets,etc.,)allowing the use of photographs and answering questions. This authorization is only valid for'the inspection date specified above, and must be renewed for any future inspection(s.) Occupants Signature/\ Date - . i r . r -. . � - - _ ` � a - .. �'. � .. - _ a� - ,._ �c - .. m TOWN OF BARNSTABLE BOARD OF HEALTH ARTICLE II: MINIMUM STANDARDS FOR HUMAN HABITATION Date Time: In Out Owner Q 9i ( ;�1� Tenant VACAi\J—r Address O eqx r�o(0 50 Address 6Aqi ),-T Compliance Remarks or Regulation # Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities �� 4. Water Supply G 5. Hot Water Facilities 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation 9. Installation and Maintenance of Facilities S 10. Curtailment of Service 11. Space and Use _ r A t ll 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal D/o ® l03OR 17. Temporary Housing 18. Driveway Width L4 q M'f s✓ ,Z� � �t1/© ��F>� 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition Number of Bedrooms Number of Vehicles we ax) Number of Persons Allowed (max) Persons Interviewed AN(%�" ( ) 4-11? ���5Ll Q Inspector L./ If Public Building such as Store or Hotel/Motel specify here TOWN OF BARNSTABLE LOCATION r4 SEWAGE _ VILLAGE ASSESSOR'S MAP&PARCEL 3/� 7S- INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY f Goo 6¢ L/C�,pi�•�� P' LEACHING FACILITY:(type) i�-/.� jay-,/ L� (size) 94? NO.OF BEDROOMS BB OWNER W drr de✓ PERMIT DATE: '7.?a-Io COMPLIANCE DATE: I 7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility �� Feet Private Water Supply Well and Leaching.Facility(If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) 7Z_ Feet FURNISHED BY&0- Tv., 9i11r` �i d /07 pLOCATION SEWAGE PERMIT NO. V I L LAG E 5"K-5 Gb f— —7 �j '�5' 3/Cc� �7 S— INSTA LLER'S NAME i ADDRESS S U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED��� ��4 g� 37 c� a r No. -, g 3 Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Rpplicatiou for aigpoal *rmem Cow5tructiou Fermat Application for a Permit to Construct( ) Repair(-,� Upgrade( ) Abandon( ) ❑Complete System E Individual Components Location Address or Lot No. �� ���f/��}- l4J , Owner's Name,Address,and Tel.No. Assessor's Map/Parcel •C/cG��f7/�'�/�� � L � ����� Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 1 GD Type of Building: (� Dwelling No.of Bedrooms / Lot Size 2.5 0ae�P sq.ft. Garbage Grinder ( Q Other Type of Building $/ No.of Persons Showers( ) Cafeteria( ) Other Fixtures !� Design Flow(min.r quired Z �Z gpd Design flow provided 71;7 9 gpd Plan Date s Z / Number of sheets l Revision Date Title I5 5yir e? 0, n Size of Septic Tank `dam 4"e— Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B d of e Signed Date 7� Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued IR j No. I V 1 $ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Application for Mi!5pogal.6pgtemi Cow5truction Vermit Application for a Permit to Construct( ) Repair(&� Upgrade( ) Abandon( ) ❑ Complete System U Individual Components Location Address or Lot No. i!1 l�?,`J//e H, Owner's Name,Address,and Tel.No. Assessor's Map/Parcel InstQller's Name,Address,and Tel. No. Designer's Name,Address and Tel.No. �� 77,/- Type of Building: Dwelling No.of Bedrooms / Lot Size Z5 r, sq.ft. Garbage Grinder (14-1Q Other Type of Building ee;I w No.of Persons Showers( ) Cafeteria( ) Other Fixtures /1[ Design Flow(min.r quired 7� gpd Design flow provided / gpd Plan Date 5— Z_ 1/,Q Number of sheets l Revision Date Title Size of Septic Tank /DDQ'yCY� ,�i('/ 9�` Type of S.A.S. m t/SDv\ Description of Soil Nature-of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of Compliance has been issued by this B d of e / Signed Date 7l D Application Approved by Date Application Disapproved by: Date for the following reasons Permit No. Date Issued > THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE5,TIFY,that the On-site Sew; Disposal System Constructed ( ) Repaired (Y11) Upgraded ( ) Abandoned( )by 2�V at C/��f e has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. _dated �/ . Installer 'p/��Q/o /t Designer �--1 �G, lc� f!'G7 ,G�La #bedrooms `� Approved design flow `7 gpd The issuance of this permit shal not be construed as a guarantee that the system will�,ucti, s desig d. Date I ! Inspector I Fee / THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS I' ligpo,5al *pgtem Construction Permit Permission is hereby granted to Construct ( ) Repair ( Upgrade ( ) /Abandon ( ) System located at 57X t/-,, i and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided: Construction must be completed within three years of the date of this 1 Date j �'� Approved by Fee l THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01ppYication for Thgogal 6p.5tem Construction Permit Application for a Permit to Construct( ) Repair X Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. C G l in Owner's Name,Address,and Tel.No. 1 .LreKr ()ltQevsm Assessor's Map/Parcel '3 l 6 /7 S 76 `j t.-1 a t k L K g q r it 5 q 1P Inst�ll `'s Name,Address,and Tel.No. Designer's Name,Address and Tel.No. I�avl�( �. O✓yh�Ztso /��t" 43 7tl�014/de (ft r 5.714 c,.l'ch, U14 9 Type of Building: Dwelling No.of Bedrooms Lot Size , �d0 sq. ft. Garbage Grinder ( ) Other Type of Buil No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow n.required) 44�o gpd Design flow provided 474-4 9 gpd Plan Date y -zi t, Number of sheets Revision Date Title � �q � rrj ��v/ ' Size of Septic Tank tD6 P p // Type of S.A.S. I Odt t/5d r Description of Soil 6P (aifl 'P Z Nature of Repairs or Alterations( wer when app ica !aintena � qDate last inspected: Agreement: The undersigned agrees to ensure the constructio the afore described on-site sewage disposal system in accordance with the provisions of Title the Environmental Code and not to place the syste in operation until a Certificate of Compliance has been issued by this B and o Pith. _ Signed - Date Application Approved by �; Date 6—;Z 1 1 U Application Disapproved by: Date for th follo r ons 5 . d©•, ermit No. 1;1010 Date Issued —��— THE COMMONWEA H OF MASSACHU ETTS BARNSTABLE, SACHUSET S Certificate of Co tan ' THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( ) Abandoned( )by at 1�(P G rg4ilt Ca Ke has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. XO �o' dated Installer �� �rj p� Designer palV i G( p yelt,ah e W r- (�S' #bedrooms V Approved design flow 4A a gpd The issuance of this permit shall not be construed as a guarantee that the system will function as designed. Date Inspector 1�. �P� Mor �M w A a m % Fee Entered in computer: �THE'COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes r F. ZIpprfcation for Migpoml bpgtem Con.5tructfon Permit Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components Location Address or Lot No. SC Gi r j k I C L In Owner's Name,Address,and Tel.No. T.�. _1 L`rehc AuQePSa�I Assessor's Map/Parcel / /7 5 SL Gr°I p4e L.k h g r K v q.b le ' Install is Name,Address,and Tel.No. Designer's Name,Address and Tel.No. VqpJa D. (01,00IJo X TP Note' J 2,U Y 43 ?ri qn � G r G 5-7yW h.l`Cti Gl?9 OZf0 4 D Type of Building: z Dwelling No.of Bedrooms Lot Size IS, 000 sq.ft. Garbage Grinder ( ) ;. Other Type of Buil No.of Persons Showers( ) Cafeteria( ) Other Fixtures M �{ Design Flow n.required)_ 44(�0 4 9 g • gpd Design flow provided 47Y• gpd { ". Plan _Date a�� 2� t w Number of sheets Revision Date J ` Title J54/ S rm Al-I 11 Size of Septic Tank 1•060 Type of S.A.S. BelodtXy..5or. Description of Soil t t / f_� Y1 n Nature of Repairs or Alterations•( wer when a ca dVif �`i![ °�704�O e(-% t�511O1�1 - x ! VS S Iq h r Date last inspected: .' Agreement: ' s The undersigned agrees to ensure the constructio aintenan the afore described on-site sewage disposal system in accordance with the provisions of Title of the Environmental Code and not to place the syste in operation until a Certificate of Compliance has been issued by this B and o dalth. Signed A Date Application Approved by - Date j' Application Disapproved by: Date e for th follo � re on s!�`^'^" ermit No. 900— 13 Date Issued THE COMMONWEAL H OF MASSACHU.ETTS BARN, SACHUSET S ti (Certificate of Co Tian THIS IS TO CERTIFY,that the On-site Sewage Disposal-System Constructed ( ) Repaired ( ) Upgraded ( ) i � Abandoned( )by a at S 6 G ra n +r C61 fir, }. has been constructed in accordance } 7- 0— dated�3 with the provisions of Title 5'and the for Disposal System Construction Permit No. Installer AO Designer p Ci V �p y�k an 0 w r S #bedrooms Approved design flow 4.4� 0 gpd The issuance of this permit shall not be construed as a guarantee that the system will function as designed. J Date Inspector No I ! � x -- yFee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS -r r Di0otar *p5tem Construction Permit Permission is hereby granted to Construct ( ) Repaid( ) Upgrade Abandon ( ) System located at G rq n i {C V1 / 1 and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local�provisions or special conditions. Provided: Construction must be completed within three years of the date of this riC- Date a' `! Approved by 1 R Town of Barnstable Regulatory Services Thomas F. Geiler, Director BARN6rABM • XA 9 ' Public Health Division Thomas McKean,Director 200 Main Street,Hyannis,MA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer& Designer Certification Form Date: Vl`7 l/G Designer: 'DhVIO D - CoVCM HUwQ R.S. Installer: Address: 43 TRI►JGLL CifZCLC Address: J SKOMCw, N 0250 On 7 Z Z�21n�57 was issued a permit'to install a (date) (installer) septic system at t5 ��G'l'�1%j A r 4/?/&'A4sed on a design drawn by (address) dated 7 Z� (designer) i/ I certify that the septic system referenced•above was installed substantially g accordin to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. OF DAVID cc�, stall stallea Signature) COUGHANOWR y No. 1093.. SgNITARIPN (Designer's Signature) ) (Affix Designer's Stamp Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU. Stanton, David From: McKean, Thomas Sent: Monday, March 29, 2010 2:22 PM To: Stanton, David; Cabot, Jaime; Desmarais, Donald; McKenzie, Marybeth; Miorandi,•Donna; O'Connell, Timothy Subject: Draft Policy/Transferring DWCP's Y franferring Disposal Works Con... 3 I contacted Brian Dudley and he had no objections to the attached draft policy. We could require the applicant to complete a new application in each case. Please let me know if you should have any comments before we proceed ahead with this. r a l 1 - t March 29, 2010 Transferring Disposal Works Construction Permits (DWCP) Transfer of Permit According to DEP, an application for a DWCP goes with tAhe'land� Therefore it can be simply transferred to another septic installer, if the bottomsectio s not already been issued to a different septic installer (bottom section removed). If the bottom section was removed,another application must be completed A ew fee will not be charged: v Significant Change in Plans: If there is a significant change to the plans, a new application shall be completed and another fee shall be charged. $` �. 4 Definition , Sinifican Gran'ei3 ans location AS to to another section of the property, K increasen�flow change to a different designer. chang iiri type of SAS, g t THE- 6 ky G z .. .. " .?' Y ,7t6�1Csa".eeisi.�f. CAcache\Temporarylnterrmet;F t .« " `! n,Permits.doc y: y. a"z .. "-,i1 � - TRANS. NO.: CITY/TOWN: g AZW77'.4 gLC APPLICANT: L RCU1-z' ANDL=RSO N ADDRESS: GR(1N'1r6' LOVE DESIGN FLOW: 440 gpd REVIEWED BY: r DATE: May , 7-1 � 2-010 N/A OK NO �* � _ .�. Legal boundaries denoted [310 CMR 15.220(4)(a)] Street, Lot, tax parcel number and lot number noted on plan [310 / CMR 15.220(4)(u)J 1/ Locus Provided [310 CMR 15.2204(t)] ✓ Plan, proper scale? (1"=40' for-plot plans, 1 '=20' or fewer for components) [310 CMR 15,220(4)] Easements shown [310 CMR 15.220(4)(b)] System located totally-on lot served [310 CMR 15.405(1)(a) for upgrades]- if not, a variance is re uired [310 CMR 15.412(4)] - ✓ Location of impervious surfaces (driveways,parking areas etc.) [310 CMR 15.220(4)(d)] Location all buildings existing and proposed 310 CMR 15.220(4)(c)] Location and dimensions of system components and reserve areas. [310 CMR 15.220(4)(e)J System Calculations [310 CMR 15.220(4)(0] daily flow septic tank capacity(required andprovided) soil abso `tion system (required andprovided) whether system designed for garbage grinder +� North arrow [310 CMR 15.220(4)(g)] Existing and ro osed contours [310 CMR 15.220(4)(g)] Location and log of deep observation holes (existing grade el. on each test) [310 CMR 15.220(4)(h)] ✓ Names of soil evaluator and BOH representative [310 CMR 15.220(4)(h) and (i)] �✓ Location and date of percolation tests (performed at proper elevation?) [310 CMR 15.220(4)(i)] Percolation test results match loading rate? [310 CMR 15.242] o/ Certification statement by Soil Evaluator [310 CMR 15.220(4)0)] Observed and Adjusted groundwater(method for adjustment ; given or indicated) [310 CMR 15.103(3) and 310 CMR 1 5.220(4)(n)J , Address ` G IL R 1 T l_1 `-�} L� Sheet 1 of 7 t t � a . N/A OK NO I;ocation of every water supply,public and private, [310 CMR / 15.220(4)(k)] v within 400 feet of the.proposed system location in the case of surface water supplies and gravel packed public water supply ✓ within 250 feet of the proposed system location in the case within 150 feet of the proposed system location in the case ` of private water supply wells Location of all surface waters and wetlands located up to 100 ft. beyond setbacks listed in 310 CMR 15.211 and any catch basins ✓ located within 50 ft. 310 CMR 15.220(4)(1)] Water lines and other subsurface utilities located [310 CMR ✓ 15.220(4)(ni)] (if water line cross see 310 CMR 15.211(1)[1]) Profile of system showing invert elevations of all system components and-the bottom of the SAS [310 CMR15.220(4)(o)] ✓ Stampof designer [310 CMR 15.220(1 and 310 CMR 15.220(2)] c/ Stamp of Registered Land Surveyor(required if construction activities within 5 ft. of lot line) [310 CMR 15.220(3)] V✓ Test Holes adequate (two in each of the primary and reserve unless trenches as permitted in 310 CMR 15.102(2) or as f approved for an upgrade under LUA at 310 CMR 15.405(1)(k)] Test hole adequate to demonstrate four feet of suitable material? [310 CMR 15.103(4)] Test Holes adequate to confirm adequate groundwater separation? [310 CMR 15.103(3)] Benchmark within 50-75' of system [310 CMR 15.220(4)(g)] Materials specifications noted? [various sections of 310 CMR 15.000] System components not>36" deep (unless Local Upgrade Approval or LUA requested) [310 CMR 15.405 1(b)] Address 6 mt'le &ev Sheet 2 of 7 i .4 ' N/A OK NO' T IN & 4k. x Size OK? [310 CMR 15.223(1)] Inlet tee located ten inches below flow line [310 CMR 15.227(6)] Outlet tee 14" or 14" + 5" per foot for increase ft depth [310 CMR 15.227(6)] Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)] Note regarding installation on stable compacted base [310 CMR 15.228(1)] Separation between inlet and outlet tees (no less than liquid depth) [310 CMR 15.227(2)] Inlet/Outlet elevations at least 12"above high groundwater (except as described 310 CMR 15.227(5)) or permitted for upgrades under LUA [310 CMR 15.405(1)(k)] Minimum cover 9" (Tanks buried more than 9" must have risers on all openings and on the d-box) [310 CMR 15:2228(1) and 310 CMR 15.232(3)(fl] Three access covers (inlet and outlet must be 20" or greater) - middle access at least 8 (by 7/07) [310 CMR 15.228(2)] Access to within 6 " of grade - one port for systems<1000gpd, two for systems>1000 gpd [310 CMR 15.228(2)] All at-grade covers secured to unauthorized access? [310 CMR 15.228(2)] > 10 ft from building foundation [310 CMR 15.211(1)] Buoyancy calculation Required/Done [310 CMR 15.221(8)] H-20 Where appropriate? [310 CMR 15.226(3)] Setbacks from resources [310 CMR 15.2111 Required when other than single-family dwelling or flow>1000 d [310 CMR 15.223(1)(b)] ✓ First compartment 200% daily flow; Second compartment 100% daily flow [310 CMR 15.224(2) and(3)] "U" pipe through or over baffle, outlet of each compartment with gas baffle or approved filter [310 CMR 15.224(4)] Address S(o �( h/�e 61 q L° .' _ t F;x Sheet 3 of 7 4 N/A OK NO Located at least ten feet from any water line? [310 CMR 15.222(2)] Disposal piping at least 18"below water line(when water and sewer cross, see 310 CMR 15.211 1 [1 ) Cleanouts required/provided ? [310 CMR 15.222(8)] Thrust blocks specified in force mains? 310 CMR 15.221(6)(c)] V Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable / 310 CMR 15.222(6)] Proper pitch on all runs? (.005 within gravity-distributed trenches and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2) c ] Siphonproblem/(leachfield below pump chamber) ✓ Endca s or vent manifoldspecified? ✓ Size and orientation of discharge holes specified? (not smaller than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310 CMR 15.252(2)(h)] Materials specified (310 CMR 15.251(5) specifies various pipe types allowed) Stable compacted base [310 CMR 15.221(2) and 310 CMR 15.232(2)(a)] Splash plate or baffle tee required on inlet/provided? (when pressure sewer to d-box or steep pitch of gravity sewer) [310 CMR 15.323(3)(a)] Riser if deeper than 9" [310 CMR 15.232(3)(0] Inside minimum dimension 12" [310 CMR 15.232(2)(b)] Minimum sum 6" CMR15.232 310 3 e) [ ( Watertight cover if<2000gpd); waterproof manhole if>2000gpd V/ [310 CMR 15.232(3)(d)] Capacity(emergency storage above working—design flow)? [310 CMR 231(2)] Proper setbacks [310 CMR 15.211 same as septic tanks)] Watertight 20-in minium access manhole at least 20" MUST BE TO GRADE [310 CMR 15.231(5)] Service components accessible (not too deep with piping, disconnects accessible) Alarm floats - alarm on circuit separate from pumps specified? Exceeds two units must have two pumps operating in lead-lag mode. [310 CMR 15.231(6) and(8)] Stable Compacted Base 310 CMR 15.221(2)] / Buoyancy calculations needed ? Provided? 310 CMR 15.221(8)] ✓' Address '; Gryl m i�e La q Sheet 4 of 7 f N/A OK NO w Calculations correct? 4 feet of naturally occurring material demonstrated? [310 CMR 15.240(1)] Required separation to groundwater? [310 CMR 15.212)] a/ , Aggregate specified as double washed [310 CMR 15.247(2)] System Venting required/provided? (system under driveway or >36" deep) [310 CMR 15.241] Inspection ports specified and within 3"final grade? [310 CMR 15.240(13)] Breakout requirements met? (No violation of breakout elevation within 15 ft ofSAS unless barrier) [310 CMR 15.211(1)[4] and Guidance Document] Chambers and Gal. in trench configuration supplied with inlet every 20 ft. [310 CMR 15.253(6)] Each structure with one.inspection manhole.(if>2000 gpd must be tograde) [310 CMR f5.253(2 Aggregate I'minimum- 4'maximum. [310 CMR 15.253 l )] 2' sidewall credit maximum 310 CMR 15.253(1)(a)] In bed configuration, inlet eve 40 s . ft. [310 CMR 15.253(6)] ✓ I E x $, Width 2'minimum 3'maximum [310 CMR 15.251 1 (b 100 feet - maximum length [310 CMR 15.251(1)(a)] Minimum separation 2x effective depth or width whichever greater 3x if reserve between trenches) [310 CMR 251(1)(d)] Situated along contours [310 CMR 15.251(2)] Breakout OK? [310 CMR 15.211 1 [4] and Guidance Document] B)CDS rC1IIli1,. F minimum 2 distribution lines [310 CMR 15.252(2)(a)] � ' Maximum separation between lines 6' [310 CM R15.252(2)(d)] ✓ Maximum separation between lines and outside of bed 4' [310 CMR 15.252(2)(e)] Aggregate depth below discharge pipes 6"minimum, 12" ,y maximum. [310 CMR 15.252(2)O] Separation between beds 10'minimum. [310 CMR 15.252(2)(f)] Bottom area used in calculations only 310 CMR 15.252(2)(i)] ✓ r Address ra' �� ' s, . -� Sheet 5 of 7 N/A OK NO Pressure Dosed System ? Provided pump and piping / calculations as required [310 CMR 15.220(4)(r)] V Pressure dosing required on all systems>2000gpd or alternative systems under remedial approval [310 CMR 15.254(2) and UA Remedial Use Approvals] ' If used in gravelless system -make sure jet is directed as not to scour soil interface Guidance Document] Inspections once per year(systems<2000 gpd) or quarterly / (>2000 d) good to note on plan 310 CMR 15.254(2)(d) t/ Construction in fill - Did the plan specify that the fill shall meet the specification of 310 CMR 15.255(3)? Impervious barrier and/or retaining wall ? [Guidance Document Impervious barrier installation must be supervised by designer [310 CMR 15.255(2)(b)] Retaining wall must be designed by Registered Professional Engineer [310 CMR 15.255(2)(a)] Side slope not exceed 3:1 ? [310 CMR 15.255(2)] o/ Breakout requirements met? [310 CMR 15.252(2) and Guidance Document] At least 5 ft. from impervious barrier to edge of SAS (10 ft. ✓ recommended) [310 CMR,15.255 (2 (e Check DEP Approval letters for credits and design conditions If used with pressure dosing do not allow pressure discharge to scoursoil interface � ]� Was DEP Approval Letter provided and/or have you reviewed the letter for conditions? Is the technology being properly applied and does it meet all DEP Approval Conditions? ✓ Is there a note on the plan regarding the requirement for perpetual maintenance agreement? Any alarms involved on separate circuits Did the applicant submit an operation and maintenance manual? Has applicant submitted a co of a maintenance .. Are the variances listed on the plan ? [310 CMR 15.220 (4)( ) RLS Stamp necessary on plan if a component is within five feet of property line [310 CMR 15.412(4)] New construction or increased flow proposed- [Refer to 310 CMR 15.414 Address S 11 �� `ft Sheet 6 of 7 S N/A OK NO Is the system in a Designated Nitrogen Sensitive Area(Zone II for a public supply well)? [310 CMR 15.214, 310 CMR 15.215 and 310 CMR 15.216 - also refer to Policy regarding upgrades of such existing systems] Is the system proposed on the same lot as served by private well ? [310 CMR 15.214(2)] Are the nitrogen loads proposed in compliance? [310 CMR 15.216(1)] ✓ s+ 4 Pumping to septic tank ? [ 310 CMR 15.229] Shared System [310 CMR 15.290] 6 Address 6 n l Lg `Q Sheet 7 of 7. Town of Barnstable Barnstable ' a Regulatory Services Department AD-A"edeaCily q� 1639, ,� Public Health Division � 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304 Thomas A.McKean,CHO CERTIFIED MAIL# 70062150000210418696 4/14/2009 Irene Anderson 56 Granite Lane ' Barnstable, MA 02632 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 56 Granite Lane Barnstable, MA was last inspected on June 11, 2008,by Patrick O'Connell, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Failed"under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Backup of sewage into facility or system component due to an overloaded or clogged SAS. You are ordered to repair oryeplace the septic system within Sixty (60) days from the date you receive this notification. Failure to repair/replace`the septic system within the deadline period will result in future enforcement action.f PER ORDER OF THE BOARD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health f n Commonwealth of Massachusetts r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Granite Lane Property Address Irene Anderson Owner Owner's Name information is Barnstable MA 02630 June 11, 2008 required for State Zip Code Date of Inspection every page. City/Town Inspection results must be submitted on this form. Inspection forms may not be altered in any way. v Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return key. Septic Inspection Services Co. Company Name „n 189 Cammett Road Company Address 02648 Marstons Mills MA �enm Cityrrown State :�� Zip Code 508-428-1779 SI 12855 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ❑ Passes ❑ Conditionally Passes ® Fails ❑ Needs Further Evaluation by the Ocal Approving Authority June 11, 2008 a Ins ctor's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. This report only describes conditions at the time of inspection and under the conditions of use p perform in the future under will time. This inspection ion does not address how the systemp at that t P the same or different conditions of use. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 08-154 Anderson.doc•08/06 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Granite Lane Property Address Irene Anderson Owner Owner's Name information is `required for Barnstable MA 02630 June 11, 2008 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not determined," please explain. ❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank isless than 20 years old is available. ND Explain: ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed 08-154 Anderson.doc•08/06 Title 5 Official Inspection form.Subsurface Sewage Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Granite Lane Property Address Irene Anderson Owner Owner's Name information is required for Barnstable MA 02630 June 11, 2008 every page. Cityrrown State Zip Code. Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system.(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 08-154 Anderson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Granite Lane Property Address Irene Anderson Owner Owner's Name information is required for Barnstable MA 02630 June 11, 2008' every page. City/town State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections! Yes No ® ❑ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due town overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or,clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 08-154 Anderson.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Granite Lane Property Address Irene Anderson Owner Owner's Name information is required for Barnstable MA 02630 June 11,2008 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000.gpd. For large systems, you must indicate either"yes or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ . the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15,304. The system owner should contact the appropriate regional office of the Department. 08-154 Anderson.doc•08106 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 15 i Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 56 Granite Lane Property Address Irene Anderson ` Owner Owner's Name information is required for Barnstable MA 02630 June 11, 2008 every page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as partof this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic jank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with. information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)) 08-154 Anderson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Granite Lane Property Address Irene Anderson Owner Owner's Name information is required for Barnstable MA 02630 June 11, 2008 every page. Citylrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ❑ No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑, No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Sump pump? ❑ Yes ® No Last date of occupancy: Currently Occupied Commercial/Industrial Flow Conditions: Type of Establishment: Design flow.(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft.,'etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): 08-154 Anderson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Granite Lane Property Address Irene Anderson Owner Owner's Name information is required for Barnstable MA 02630 June 11, 2008 - every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: None Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system.owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 08-154 Anderson.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 8 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.-,Not for Voluntary Assessments 56 Granite Lane Property Address Irene Anderson . Owner Owner's Name information is required for Barnstable MA 02630 June 11, 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well orsuction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): Depth below grade: 2'feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene El.other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes. ❑ No ------------------------ ------------------------------------------------------------------------------------------------- Dimensions: 8.5' long x 5.2`wide 1000 gal. Sludge depth: 3 Distance from top of sludge to bottom of outlet tee or baffle 27 Scum thickness 2 Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 12" How were dimensions determined? Measured 08-154 Anderson.doc-08/06 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form _ 6 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM 56 Granite Lane Property Address Irene Anderson Owner Owner's Name information is required for Barnstable MA 02630 June 11 2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Liquid level was found at bottom of outlet invert, baffles are intact. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): 08-154 Anderson.doc•08/06 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 56 Granite Lane Property Address Irene Anderson Owner Owner's Name information is required for Barnstable MA 02630 June 11, 2008 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank (cost.) Dimensions.- Capacity: - gallons , Design Flow: gallons per day a Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date . Comments (condition of alarm and float switches, etc.):` s_ `Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: El Yes ❑ No Alarms in working order: ❑ Yes ❑ No 08-154 Anderson.doc-08/06 Title 5 Official Inspection Form:SJbsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments w„ 56 Granite Lane Property Address Irene Anderson Owner Owner's Name information is required for Barnstable MA 02630 June 11, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® Teaching pits number: One 6x6 pit. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields . , number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Hlgh stain lines in pit indicate liquid level had been at top of structure, pit is in hydraulic failure. 06-154 Anderson.doc-08/06 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 56 Granite Lane Property Address Irene Anderson Owner Owner's Name information is Barnstable MA 02630 June 11, 2008 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate.on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 08-154 Anderson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 56 Granite Lane Property Address Irene Anderson -- - _...__...------------ -..-...................................... _..---- - --------------_-_....--- Owner Owner's Name information is Barnstable MA 02630 June 11, 2008 requiredfor - ._..._.--._.._..__.._..---- ..__....-- --- — --...— —-- --- every page. City/Town State Zip Code, Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Granite Lane Water Service 66 20 - 37 ;tn; r 83 r Commonwealth of Massachusetts W Title 5 Official Inspection Form e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 56 Granite Lane Property Address Irene Anderson Owner Owner's Name information is required for Barnstable MA 02630 June 11, 2008 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to ground water: N/A feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers - (attach documentation) ❑ Accessed USGS database - explain: You must describe how you established the high ground water elevation: 08-154 Anderson.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 DATE OF TEST: APRIL" D. 2�J10 DESIGN �C �AL_ ,CULATIONS SOIL - T E S T L O Ge SOIL•EVALUATOR: `DAVID D. COUGHANOWR. R.S. ' WITNESSED =BY: DAVID STANTON. HEALTH DEFT. - �f PERC NUMBER: -' 12906 DESIGN FLOW: 4 BEDROOMS X 110 GPD 440 GPD .. - - § TEST PIT 1 NO GROUNDWATER ENCOUNTERED SEPTIC TANK: 440 GPD X 2 DAYS 88.0 GALLONS PARENT MATERIAL: .PROGLACIAL OUTWASH INSTALL 1500 GALLON SEPTIC TANK (MINIMUM ALLOWED) PERC AT 62 in — 2 MIN✓INCH IN C3 SOILS DISTRIBUTION BOX: USE 3 OUTLET H-20 D—BOX. ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING SOIL ABSORBTION SYSTEM: INSTALL 13 ADS HIGH CAPACITY BIODIFFUSERS (1600BD) 50.44 _ 13 UNITS x 6.25 Ft. / UNIT 81.25 L.F. 0-4 O LOAM 10 YR 2/1 NONE FRIABLE 61.25 L.F. x 7.90 S.F./L.F = 641.66 S.F. 4-10 A LOAMY SAND 10 YR 4/6 NONE FRIABLE A 641.88 S.F x .74 G.P.D. / S.F. = 474.99 GPD 10-30 B LOAMY MED SAND 10 YR 5/6 ' NONE FRIABLE USE 13 HIGH CAPACITY BIODIFFUSERS AS CONFIGURED BELOW - Vt = 474.99 GPD > 440 GPD REOUIRED 30-44 Cl MEDIUM SAND 10 YR 5/6 NONE LOOSE REFER TO DEP APPROVAL LETTER TRANSMITTAL & W000052 FOR CERTIFICATION 44-68 C2 SILTY SAND 10 YR 5/3 NONE FIRM OF ADANCED DRAINAGE SYSTEMS BIODIFFUSER SYSTEMS, 44.77 68-136 C3 MEDIUM SAND 10 YR 6/4 NONE ' LOOSE 38.94 ' NO GROUNDWATER ENCOUNTERED 1000 GALLON SEPTIC TANK DIMENSIONS AND DETAIL NOT TO ' TEST PIT 2 PARENT MATERIAL: PROGLACIAL OUT.WASH USE EXISTING H-10 UNIT SCALE 2 MIN/INCH IN C3 SOI.LS LEACHING e I ELEVATION L E/l CHING GALLERY L ER Y NOT E, SEPTIC TANK IS TO A PUMPED DRY DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER SCALE AT TIME OF INSTALLATION AND rs To (INCHES) HORIZON TEXTURE (MUNSELL) MOTTLING IN EXAMINED FOR STRUCTURAL PVC CONSTRUCTION DETAIL A I L .- LNTEGRITY. INSTALL NEW PVC OUTLET 50.63 ' TEE EQUIPPED WITH A GAS BAFFLE: LOAM 10 YR 2/1 NONE, FRIABLE USE ADS HIGH CAPACITY BIODIFFUSERS ftt 0-4 O - 1600BD1. GRAVELLESS 4-12 A. t LOAMY SAND 10 YR 4/6 NONE, FRIABLE s, a TAPER I ' INSTALLATION USE DEP APPROVED INSTALLATION PROCEDURES. w 37.50 Ft . ^ 12-32 B LOAMY MED SAND, 10 YR 5/6 NONE FRIABLE r 32-45 C1 MEDIUM SAND 10 YR 5/6 NONE LOOSE F7 M. o 45—?0 C2 SILTY SAND 10 YR 5/3' NONE FIRM � � 1p o 44.80 70-138 C3 MEDIUM SAND 10 YR 6/4 NONE LOOSE CD CD 39.13 4 C DISTRIBUTION BOX N g f£_s A k �m _ DIMENSIONS AND DETAIL USE SF#3REY G&-3 H-20 43.75 f-t INLET OUTLET COVER COVER — - CROSS SECTION VIEW NOT TO ::-12 i r. a ., —> Ili IN CROP FLOWLINE ' SCALE ` . _ FROM 10!n = 14 TO . -, , !.: —► BUILDING MIN USE H-20 ,n p-Box .♦ pp .F r .i! +et 1r• 1.�' {Iltl+nvxr.y,i t,;r - FROM —� - - - - 4in w y, m R.9 TED UNITS Lrouro TANK 03 A TO 16 11.3 in • LEVEL GABAFFLE - t In EFFECTIVE DEPTH 6 u-r STONE BASE _ k:• _ - .:... . ...: CROSS SECTION VIEW I 34 in f2.63 Ft7 l 68,In 15.66 FL) �, 34 to (2.83 Ft7 SEPARATION OF INLET AND OUTLET TEES SHALL BE NO LESS THAN LIOUID DEPTH NOTESCROSS SECTION VIEW.' 1' v 1) INSTALLER TO OBTAIN DISPOSAL 'WORKS PERMIT BEFORE STARTING WORK. - 2) SEPTIC TANK TO BE PUMPED DRY AT TIME OF SYSTEM REPAIR AND CHECKED FOR STRUCTURAL INTEGRITY. INSTALL PVC OUTLET TEE FITTED WITH GAS BAFFLE. 3) ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM REOUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC CODE (310 CMR 15). 4) INSTALLER TO VERIFY LOCATIONS OF ALL UNDERGROUND UTILITIES BEFORE EXCAVATING FOR SYSTEM. GROUNDWATER ADJUSTMENT SEWAGE DISPOSAL SYSTEMH PLAN 5) EXISTING LEACH PIT TO BE PUMPED, COLLAPSED, ANDFILLED OR REMOVED. "' EXISTING GROUNDWATER LEVEL -TO SERVE EXISTING DWELLING 6) ALL STONE TO BE DOUBLE WASHED AND FREE OF IRON. FINES AND DUST. IN PLACE. BASED ON TOWN OF BARNSTABLE GIS DEPARTMENT RECORDS. 7) ECO—TECH ENVIRONMENTAL RECOMMENDS THE INSTALLATION OF LOW FLOW FIXTURES IRENE ANDERSON AND APPLIANCES. AND BIANNUAL PUMPING OF THE SEPTIC TANK. INDICATED GW 22.00 8) SYSTEM IS NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. DO NOT INDEX WELL AlW-247 56 GRANITE LANE BARNSTABLE: MA ' .PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. ZONE C READING DATE APRIL. 2010• ECO-TECH ENVIRONMENTAL 9) SEPTIC TANKS SHALL BE INSTALLED LEVEL AND TRUE TO GRADE ON A LEVEL ` READING 20.0 STABLE BASE THAT HAS BEEN MECHANICALLY COMPACTED AND ON TO WHICH ADJUSTMENT e 43 TRIANGLE CIRCLE SANDWICH MA 02563 SIX INCHES OF CRUSHED STONE HAS BEEN PLACED TO MINIMIZE UNEVEN` SETTLING. ADJUSTED GW 22.00 ETE-3332 MAY 21. 2018 2/2 • 50" 46 44_ 42 40 - 200.00 Ft 62 60 _ 58 - 56 - 54 _ 52_- - 48 -_�5� -_ CONTOURS ROUTE 6A 64 - - - - EXISTING - - - - 50 N FINAL 50 SALT ROCK ROAD LOT 73 rn VENT \ \ ❑ I \ \ \ \ PIPE y \ I\ ARE� = 25000 s f +- LOCUS I Ioc> \ \\ \ � �16 GRANITE � 66\I, \ \ m PC9 LANE LINE \ {t TP-I m< O�vP�' V l � I WA 24 0 I �t \ \ G 19 0\ \ I BARNSTABLE. MA m I \ \ \rn� LOCUS MAP Z 68 � rn � I �O \ \ \ F O Q] X \ \ _ 18 0 0 I NOT TO SCALE \ 11 rn rn H - 16-0 \ I I O \ �� -� 1 -�-40 LEGEND I� \ I � I Z 0 z 3 \ I EXISTING O ze-D\� \ 1000 GALLON + z \ Z 0 \ \ 45 I m BENCH MARK SEPTIC TANK \ \ <k\0 a \ I"� PAINT SPOT ON EXISTING LEACH BOULDER m I \ \ \ Ao3 PIT/CESSPOOL \ I ELEVATION = 46.16 " \ \ \ \ < I BARNSTABLE GIS. DATUM I \ \ �ti TEST PIT ® H-20 D-BOX HYDRANT O GPS/ \ I DECIDUOUS CONIFEROUS 7 6B I / � � \J� TREE *2-MTREE �1� 2-P Y� Q\ 1\ � 18-0 i GARBAGE GRINDER NUMBER REFERS TO DIAMETER IN ❑RIV IS NOT ALLOWED INCHES. LETTER DENOTES TYPE. PAVED \ \ \ \ I I NG WALL WITH THIS DESIGN. D OAK M-MAPLE P PINE C-CEDAR \ I RETAIN I \ I H OF MgSS9c N OF MgSsq tic o� cy \ I I o DAVID � DAVID p D. COUGHANOWR - " COUGHANOWR cn —7 42 No. 1093 -- —� 200.00 Ft �rq •52 50 `1H 46 44 p 56 'Q S / O 64 60 58 FG/STERN OA< CENS� 0 66 62 IDL/ 1/ V ALL PIPE O W PROFILE, SCALE: 20 f t SPECIFIED ARE INVERT EXPRESSED INVATIONS DECIMAL FEET NOT FEET AND INCHESTIONS — PE PIPE 1 in = RAISE COVERS TO WITHIN 20 0 20 40 AC4 Y TOP OF FOUNDATION 6 in OF FINAL GRADE EL =63.45 +- 50.0 � e 10 20 ��®� ���� SEWAGE DISPOSAL EXISTING INGYDwELLIN DWELLING _ IAN INSPECTION VARIANCE REQUESTED EST. I R E N E A N D E R S O N /D-BOX 5 PORT (ONE OWNERS OF RECORD 3" D P USE H-20 MAX PER TRENCH) MAY BE GRANTED IMMEDIATELY BY FEAL TH AGENT OR HEALTH INSPECTOR. RO FLOW LIN 310 CMR 15.221(r7) - COMPONENT � �I 56 GRANITE LANE ID.. _ TEE 45 00 DEPTH TO FINISH GRADE. 36 Tn ��® 1995 �v BARNSTABLE. M A ' EXISTING 14 ry____ __ _= __ MAX REQUIRED - VARIANCE TO 4e" �As� = 6lZ1 In OF COVER REQUESTED. �ON PROPERTY ADDRESS BAFFLE 53.44 6 i n ________---= ----=__-=_ ASSESSORS MAP 16 PARCEL 5 ---__----_---_- --_ 43 TRIANGLE CIRCLE EXISTING �/ T r STONE 44.73 -_------_-______-------- BOTTOM OF SANDWICH MA 02563 PLAN BOOK 222 PAGE 85 EXISTING BASE LEACHING SOIL ABSORPTION 44.90 1 SYSTEM 508 664-8894 DATE: MAY 21, 2010 1 GALLON A L O N 44.61L43. SYSTEM JOB #E T E-3 3 3 2 PAGE 1 O F 2 VERSION. 1 L7 5.00 ft+ THIS PLAN IS BASED ON AN INSTRUMENT SURVEY AND IS INTENDED SEPTIC TANK 7 Ft E DETAIL ON REVERSE SOLELY FOR INSTALLATION OF THE PROPOSED SEPTIC SYSTEM EXISTING'11 20 FL 22.0 ADJUSTED DEPICTED HEREON. FOR ANY OTHER CHANGES TO PROPERTY INCLUDING SEASONAL HIGH PLACEMENT OF ADDITIONS. SHEDS, FENCES OR SWIMMING POOLS. OWNER GROUNDWATER SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR.