HomeMy WebLinkAbout0028 HAMSTEAD LANE - Health `�$�Karnstpazf Lanen`=
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Barnstable F/R' _
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A.= 349 094 �
Lam° ���• -
TOWN-,OF BARNSTABLE
L~OCATIdN,� � �70 % /�� N SEWAGE # D � I
VILLAGE �'C>/�9i�1� f�� ASSESSOR'S MAP&LOT
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INSTALLER'S NANUi'&PHONE NO. �� ,
SEPTIC-TANK CAPACITY, 6,Y v1 J
LEACHING-FACILITY: (type) c3" 0z���, /per+ -/I (size)
NO.OF BEDROOMS
r
BUILDER OR OWNE 41Jp_29';CJ d l.!
PERMTL DATE: COMPLIANCE DATE: .2 '13 r 6 3
Separaii&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) Feet
Furnished by;
;.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form aq�b
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 28 HAMSTEAD LN
Property Address
BURLINGAME'
Owner Owner's Name
information is required for CUMMAQUID MA 6/13/13
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not bip altered id'any
way. Please see completeness checklist at the end of the form. .
Important:When filling out A. General Information
I
forms on the
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return °
key. DOUGLAS A BROWN INC
Company Name
P.O. BOX 145
Company Address
.CENTERVILLE MA 02632
Citylrown 'State i Zip Code
508-420-4534 S14297
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 i aWectiM
,Was performed based on my training.and experience in the proper function and maintenance of,o site
sewage disposal systems. Lam a DEP approved system inspector pursuant to 9e6666.15.340 of o
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6/13/13
I nspe-75t5.tignature u 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 owned'
and copies sent to the buyer, if applicable, and the approving authority. yr r
****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•3113 F Title 5 OMlnnsion onn:Subsurface Sewage Disposal System•Page 1 of 17 �.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
M 28 HAMSTEAD LN
Property Address
BURLINGAME
Owner Owner's Name
information is required for CUMMAQUID MA 6/13/13
every 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
t
A) System Passes:
® I 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:
SYSTEM MET OR EXCEEDED MINIMUM PASSING REQUIREMENTS-AT TIM OF INSPECTION
•
B Sy*stem Conditionally Pass
es:
❑ 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", "no"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):
3
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth-of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M . ' 28 HAMSTEAD LN .`
Property Address
BURLINGAME
Owner Owner's Name
information is.required for CUMMAQUID MA 6/13/13
-
every 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 ❑ Y ❑ N ❑ ND,(Explam 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 ofthe Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
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 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
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 i, Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
28 HAMSTEAD LN.
Property Address
BURLINGAME
Owner Owners Name
information is required for CUMMAQUID MA 6/13/13'
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail+unless the Board of Health (and Public Water Supplier, if anyy'j
determines that the system is functioning in a manner.that protects the public iewth,
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.
❑ 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 passesif 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:
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 to an overloaded or clogged SAS or cesspool
❑ ® F 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
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments --
28 HAMSTEAD LN
Property Address r
BURLINGAME -
Owner Owner's Name
information is required for CUMMAQUID MA 6/13/13
'
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® 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.
El ® Any portion of cesspool or privy is within 100.feet of.a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within'a Zone 1 of a public-well.
El ® Any portion of a cesspool or privy is within 504eet-of a,private water supply well:
❑ N 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.
0 ® 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 it
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. i
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
❑ El 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.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4�M , 28 HAMSTEAD LN
Property Address '
BURLINGAME
Owner Owner's Name
information is required for CUMMAQUID MA 6/13/13
every page. Citylrown 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,&Health
❑ Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the,previous'N aweek 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 andexamined?(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 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?
® El information
the facility owner(and occupants if different from owner) provided with
information on the maintenance of subsurface sewage disposal systems?
proper 9 p Y
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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
f `
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
VOy�- 28 HAMSTEAD LN
Property Address
BURLINGAME -
Owner Owner's Name
information is CUMMAQUID MA 6/13/13
required for _
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description: `
ACCORDING TO AS-BUILT SYSTEM CONSISTS OF A 1500 GALLON TANK Q=BRAND 3 500
GALLON CHAMBERS
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
Seasonaluse? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage(gpd)):
Detail
BETWEEN 375 AND 245 GPD IT WAS DETERMINED THAT THE IRRIGATION SYSTEM HAD A
LEAK AND WAS CAUSING EXTREMLY HIGH WATER USAG FOR SOME TIME I REVIEWED
PAPER WORK FROM THE WATER DEPT AND IT SHOWED NORMAL USAGE WHEN
IRRIGATION SYSTEM WAS NOT IN USE
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment: . T
Design flow(based on 310 CMR 15.203): Gallons per-day(gpd) '
Basis of design flow(seats/persons/sq.ft., etc.)-
Grease trap present? El Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑• Yes ❑ No
I .
Water meter readings, if available:
t5ins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 28 HAMSTEAD LN
Property Address
BURLINGAME
Owner Owner's Name
information is required for CUMMAQUID t MA 6/13/13
every 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:
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)
El Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of:the I/A system by system operator under contract
Tight Attach a copy of the DEP approval.
a
❑ 9
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 HAMSTEAD LN
Property Address
BURLINGAME '
Owner Owner's Name
information is CUMMAQUID MA 6/13/13
required for '
every page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
FEB OF 2003
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ casoron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction 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 ❑ 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: 1500
Sludge depth: LIGHT
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 HAMSTEAD LN
Property Address
BURLINGAME
Owner Owner's Name
information is required for CUMMAQUID MA 5/13/13
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.) M
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness. ' • _
LIGkT., .f
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? WOODEN POLE
Comments(on pumping recommendations, inlet and outlet tee or baf�e condign, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
RECOMMEND PUMPING EVERY 2-3 YRS
r ,
Grease Trap(locate on site plan): T
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑gther(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
f ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 28 HAMSTEAD LN " s.
Property Address
BURLINGAME
Owner Owner's Name
information is CUMMAQUID MA 6/13/13
required for
every page. Cityfrown 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.):
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.):
T
*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
F
Commonwealth of Massachusetts
W Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 28 HAMSTEAD LN
Property Address
BURLINGAME
Owner Owner's Name
information is required for CUMMAQUID MA 6/13/13
every page. City/Town State Zip Code -Date of Inspection'
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):,
Depth of liquid level above outlet invert 0.1
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.):
BOX SHOWED NO SIGNS OF FAILURE SLIGHT SCUM LAYER IN BOX
Pump Chamber(locate on site plan):
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:
DEPTH NORISERS FOUND
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
s. 28 HAMSTEAD LN
Property Address '
BURLINGAME
Owner Owner's Name
information is _
required for CUMMAQUID MA 6/13/13
every page. Cityrrown State Zip Code Date of Inspection.
D. System Information (cont.)
Type:
❑ leaching pits number:,, w -
._® leaching chambers number: 3
❑ 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,.soiry 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 ET Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°.' 28 HAMSTEAD LN
Property Address
BURLINGAME
Owner Owner's Name
information is CUMMA UID MA
req wired for
Q 6/13/13
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
28 HAMSTEAD LN
Property Address
BURLINGAME`
Owner Owner's Name
information is required for CUMMAQUID MA 6/13/13
every page. Cityfrown 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
r
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 28 HAMSTEAD LN
Property Address
BURLINGAME,
Owner Owner's Name
information is required for CUMMAQUID MA 6/13/13
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 high ground water: GREATER THAN 5.,'
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: 6-2013
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:
DESIGN PLAN
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
. Commonwealth of Massachusetts
Title 5 Official Inspection Forma
Subsurface Sewage Disposal System..Form--Not for Voluntary Assessments
GSM 28 HAMSTEAD LN '
Property Address
BURLINGAME
Owner Owner's Name
information is required for CUMMAQUID MA 6/13/13
every page. Cityfrown 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
® Sket&of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
f •
Assessing As-Built Cards Page 1 of 1
I TOWN OFBARNSTABL.E
LOCATION X SEWAGE li
VILLAQE t�L ASSESSOR
'S MAP&LOT
lNSTALLFR'SNAME PHONEN6. 77 6
SEPTIC TANK CAPACTIY '�'�'N/./SM �T
GEACHIi!tG FACIIITY:.(tyPe) 3���9•ey���f Wf-// (size)-
Kje3�X�
t NO.OF BEDROOMS
BUILDER OR OWNER. l1� ,3`G/l1
�.
PERMIT DATE: COMPLIANCE DATE: "
Separation Distance Between the:
Maximum Adjusted GroundwiterTable to the Bottom of Leaching Facility Feet
Private Water Supply Welland Leaching Facility (If any wells exist ,
I 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) Feet '
tiFurnished by
q uacKw_t��
L.
http://www.town.bamstable.ma.us/Assessing/IIMdisplay.asp?mappar--3 49094&seq=1 6/14/2013
No. —" r® f Fee v
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zippitration for Mtopaal *p!5tem Congtructton Permit
Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) EJ Complete System El Individual Components
Location Address or Lot No.�U �� ��� /AKV Owner's e,Address and Tel.No.
ne is csVl
Assessor's Map/Parcel
Installer's Name,Addres*%18.ICANCO Sesigner's Name Address and Te o.
350 Main Street oWn
W. Yarmouth, MA 02673
Type of Building: 1_
Dwelling No.of Bedrooms / Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures /�//
Design Flow gallons per day. Calculated daily flow WO-gallons.
gallons.
Plan Date M 3 Number of sheets l Revision Date OV.Z14
Title j i ll e � cSi k- Pkn
Size of Septic Tank t_fd U Type of S.A.S.
Description of SoilAA')
Nature of Repairs or Alterations(Answer when applicable) f
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 Environ 1 Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board a th.
Signed - --- Date i as 3
Application Approved by Date 0
Application Disapproved for the following reasons
Permit No. ��v�3 0v- f Date Issued
Fee �/
y THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Yes
ZippYication for Migool *pztem �tCongtructioi� ertnit
Applicatiofih&a Permit to Construct( )Repair(t`Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.o8 �5��C� (L�y�� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel, ({
Installer's Name,Address,and Tel.No. »- Designer's Name Address and TeL.No.
3 ``l
Type of Building:
Dwelling No.of Bedrooms 1 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.x
Plan Date Number of sheets / Revision Date ✓U/A
Title
Size of Septic Tank_e-,n'If o, /CO U Type of S.A.S.
Description of Soil �A/J
i
y, Nature of Repairs or Alterations(Answer when applicable) C 864
Date last inspected: '!
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
r in accordance with the provisions of Title 5 of the Environpe= 1 Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board eal th.
Signed Date 1/Qa 3
Application Approved by Date 0 _42
Application Disapproved for the following reasons
Permit No. �d�3 0 w f Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired Graded( )
Abandoned( )b C__ ��
at C1_V� �er t4 G i g i has been construct/Ed in,accordance
Zb
with the provisions of Title 5 and the for Disposal System Construction PeAt No. 2 �'�i 051 dated I! 3b 10 3
1 P
:Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system.,w�fune�i , des gned.
Date 2 J/.3/03 Inspector
i..i o. � "���� -------------------------N " `-�V3 Fee �y
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Ii6pozal *p!5tem Couttruction Permit
Permission is hereby gran ed to Co9syuct( Repat ( tol U grade( )Aban ( )
System located at IT IS� GP GI m o"A
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 permit.
Date: Approved byv't
i
TOWN OF BARNSTABLE
LOCATION SEWAGE # 103
VII.LAGE ) - ASSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 6X
53
'x
LEACHING FACILITY: (type)� �' L (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: '' `
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 Feet
within 300 feet of leaching facility)
Furnished by
i
O
133
of ►
Ae 341— ®q�
1 O C �.=T-.10N . SEWAGE PERMIT NO.
VILLAGE
J
INSTA LLER'S NAME II< ADDRESS
F 9 4AI LP Y Rd (e nv
.B UILDE.R OR OWNER
DATE PERMIT ISSUEDAre
� �er 78
DATE COMPLIANCE ISSUED
� r
�n ,z
i
No.. ..� FEa.....rd...............
a THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�7aw. .....................OF........
' '._„.. u
Appliration for Uhiposal Works Toustrnrtiun Permit
Application is hereby made for a Permit to Construct (YI) or Repair ( ) an Individual Sewage Disposal
System at:
<6} .............................. �o T 3
..... .... . _. - ' .- ...-----------....._...--..:............................................................
ocation d r or Lot No.
.. ........ .................................. ............................................
- ..... .._.................
W Address
a ................................... ..... .......................................... ...........-•-...............•............. :.:.. ...........
nstaller Address
Type of Building Size Lot... ..Sq. feet
�.•a Dwelling—No. of Bedrooms.._.........�...........................Ex panion Attic ( ) Garbage Grinder ( )
Other—T e of Building a Other—Type g ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------•.......-------•--.............---- ---------......--•---........---.....--•-•----•-•------•--•--
W Design Flow_____.___..�� :................gallons per person`per day. Total daily flow..._. ...................gallons.
WSeptic Tank—Liquid capacity,54W-gallons Length._ 4._._.. Width.... .......... Diameter................ Depth....Y.......
x Disposal Trench—No. ................... Width.................... Total Length..................... Total leaching area-__-.r____......_.sq. ft.
Seepage Pit No...... ............ Diameter... Depth below inlet......:.......... Total leaching area.Z...... -ft. �P•�
Z Other Distribution box (X) Dosing tank ( )
Percolation Test Results Performed by..4v:R.w..
----W-t;.E12 L rV 5�;.: Date... ...-. .."' ..
Test Pit No. I...............mmutes per inch Depth of Test Pitll:- !-_........ Depth to ground watertVOT..9.ffV__--^
fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit..............._.... Depth to ground waterCO v"➢: �
a .............................. ..........................:.
no
O Description of Soil............. ........ •-•----••-------------------•----•--......----•-•---•---•-•---•---...............-•----.
x
U --•..............•-••-----------•---•---.................--••••------•--••..._--•-- ----•-------....---------...------------....-•-•-----------••••----•.....------...............................
V Nature of Repairs or Alterations—Answer when applicable...........................•.•.........__......___.........._...................................
•---- --•-----------••-•••-•----•--••--•----•---•--•-----•-----•••--•----•-•••--•--.......•--•-----•-•--••-••--•-••-----••----•--•-••--•------...••--•.....•-•-•---•-•-•••••-••---•.........••.........
Agreement:
The undersigned agrees to. install the aforedescribed Individual Sewage DisppggSystem in accordance with
the provisions of I.'L. 5 of the State Sanitary ode— The ur ersigned f r-ees-not to place the system in
operation until a Certificate of Compliance has ' ,bq e board
ned
Application Appr • --------- --- ',✓..............................................................
Date
Application Disapprove f o e following reasons----------------•--••---•------••------------------......----•---•-------...----.....---......_...................
.......................................................•---------•---•-----•-------•----........•........._.....:-----...-_..------•---•-•-•-•----•-•--••-------...-----•-•--•---•-.........--•-•........
Date
PermitNo......................................................... Issued........................................................
Date
}
THE COMMONWEALTH OF. MASSACH'USETTS4 ,
BOARD OF HEALTH" °
7Qr.�1�1 .......OF......
1 -) ` Appliration for Disposal Works Tons#rurtion Frrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
.............................. ................... L
............................. ...........................................
FFoc__ation 'Ad or Lot No.
................... .. ..[6a .! ........ ............••.. ................ .........•-------.............._••-••....-••••-............•..._..._._....• _...................
W O Address
a .............................••••.. ....... ....................... .................•-•--•.......••••-•.....----
nstaller Address
Type of Building Size Lot... .�ery__Q. ...Sq. feet
Dwelling—No. of Bedrooms.............._..........................Expansion Attic ( ) Garbage Grinder
aOther—Type of Building .................. ..... No. of persons............................ Showers ( ) - Cafeteria ( )
Other fixtures +° ` """
..•-----.-------•------•----------------------••--------..........---•--....-•---•-•-----•-•--------....
ir
W Design Flow...........1J ...A gallons per person per day. Total dail flow..... .Q.5.0.......................
WSeptic Tank—Liquidcapacityl6Q,0gallons Length... --,?--'.... Width.... ........ Diameter:........:...... Depth..___!.__.
x Disposal Trench—No..................... Width_ :........ Total Length.................... Total leaching area............_........sq. ft.
Seepage Pit No......./............ Diameter..../Zi.!57'. Depth below inlet................ Total leaching area. /.4,.L?sq,-t.6 ie,o
Z Other Distribution box ( Dosing tank ( )
a Percolation Test Results Performed by..l..4?.W.._�.... r=�_L�. /2r...L_tL1 a. Date.../-.......
Z.(�a.." .....
1 Test Pit No. 1.....4......minutes per inch Depth of Test Pit-1.}19':...... Depth to ground waters.2A.7'..t"aJ
fT4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water4;.p G?!u &M
---------------- - - .
........................................................................
5
O Description of Soil...........
.....................................-........................................................................
x
U ............................•-•--------•-•--•------••-•-•------------....---•-----.--•---....................---........................................................:...............................
W .
------------------------- ................------------------------------------------------------=-•----•----•-•-------------......------•-••----•-----------•---•....-•------ ---••----._...._.._------
U Nature of Repairs or Alterations—Answer when applicable..............................................................................................
••------•-------------------------•-•-----------......._..---•----------•--•-----------...--•----•----•---•-•-------------------------------•-•----------•---------------------......---••-----._.......
Agreement:
The undersigned agrees to install the aforedescribed. Individual Sewage Disp,o�sal'System in accordance with
the provisions of TITLE 5 of the State Sanitary ode— The undersigned further 4grees-not to place the system in
operation until a Certificate of Compliance hast,.,sued`byhe board roflit/
�7 f
r+ err-• �. ._.
Application Appr r-----------•............. f_ _ ..
----------
Date
Application Disapprove f o e following reasons----------------•--......---••-------------------------••------....-•----------....-•--------•-....----••--•••••• .
--•-••-•-----•..................•-----•-----•-----•-•--------.....--------...------....------------.............---------•-------.......---•-•---•-----•• ..............................................
f Date
PermitNo.......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Trr#ifiratr of Tontplianr
T
IS CERTIFY, That e Ind* id al Se ; ge Disl System constructed ( y �o Repaired ( )
by 5 ' �,r- -- • :.-`-== --------------•.......--------------•------•--. .�--.. ............................... .
In er
at ............ ........................ °... --- . 1.
has been insta]ed in accordance with' ie provisions of TIT5 of h State Sanitar Code s ed In the
Y
application for Disposal Works Co lstruction Permit No....... . -06 dated_. !_
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS_A GUAR NTEE_THAT.THE
SYSTEM WILL FUNCTION SATISFACTORY
DATE................................................ `..... Inspector .............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............
No
t'o ro rko Ton#rnr#ion rrnti#
Permission is e y gr" -•----........... ..... ..............•--•------....... . ...---•----•---........-•.•--•-
to Construct ( or )-a nd•vi. System
atNo.-- ....... •--• •-----•-- :... ----- -------------------------
stre t
as shown /theplicat' n for Disposal �'��orks onstructi ermit .............. Dated..__-_______.__..........................
Board of Health
DATE..� $ ................................................
TOP FN DN. AT EL. 82.2' PROVIDE IF NEC. SYSTEM PROFILE TEST HOLE LOGS
ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE)
LOW AND WELLER, INC.
ACCESS COVER (WATERTIGHT) TO
ENGINEER:
F MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN, GRADE 2% SLOPE REQUIRED OVER SYSTEM 80 3, JOHN JACOBi, AGENT
WITNESS:
w
2" DOUBLE WASHED PEASTONE DATE: 11/961/83
TOP EL. 78.6' RUN PIPE LEVEL
FOR FIRST 2' 3' MAX. PERC. RATE _ < 2 MIN ANGH
EXISTING 1500L11�
z
GALLON SEPTIC 77 2't* 77.30' CLASS i 501L5 P# ooaaL DR.
j,.
TANK (H- 10 ) GAS Cl 0 L7 00 O El I`
�� �
j '�'•• RE-USE AFFLE � ao ,
7 '7 76.47 m 0 0 EO E3 0 0 0 0 0 4' AROUND
6" CRUSHED STONE OR MECHANICAL 0
80 2' a000 [� 0L7C7C] oa 74.47' Q Q EL799,
COMPACTION. (55.221 [2)) c�o �i -
DEPTH OF FLOW % SLOPE
4 MIN ( 1 ) 3/4" TO 1 1/2" DOUBLE WASHED STc.;NE 1+,�,MSTE,�o LANE
TEE SIZES: ( 7. SLOPE) LOAM & SUB
Locus
INLET DEPTH 10"
� WITH FINES
14"
OUTLET DEPTH 360. 6.9' LOCATION MAP NTS
7
FOUNDATION-- EXIST. SEPTIC TANK 29' D' BOX 13, LEACHING ASSESSORS MAP 349 PARCEL 94FACILITY 6 57
*CONFIRM OUTLET --
INVERT PRIOR TO
INSTALLATION OF ANY FINE SAND
PORTION OF SYSTEM
WITH TRACES
CONFIRM SUITABLE 67,9' OF FINES
SOILS IN AREA OF
LEACHING FACILITY
PRIOR TO
INSTALLATION
144" 67.9'
�� LOT 3 I NO WATER ENCOUNTERED NOTES:
46,057f SO. FT. -I-
0 1.06t ACRES ASSUMED
SEPTIC DESIGN: (GARBAGE DISPOSER Is NOT ALLOWED ) 1 . DATUM IS
DESIGN FLOW: _4 BEDROOMS ( 110 GPD) = 440 GPD 2. MUNICIPAL WATER IS EXISTING
USE A �440, GPD DESIGN FLOW 3. MINIMUM PIPE PITCH TO FEE 1 /F" PER 1-nnT
BENCH MARK CORNER OF
/ FLAG STONE STEPS
7 ELEVATION = 82.5 ,N SEPTIC TANK: 440 GPD ( 2 ) _ 880 4. DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10 .
+ 81.4 / DECK 1500 5. PIPE JOINTS TO BE MADE WATERTIGHT.
/ USE A -__� GALLON SEPTIC TANK (RE-USE EXISTING) 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE: WITH MASS.
00 LEACHING: ENVIRONMENTAL CODE TITLE V.
SIDES: 2(33.5 + 12.83) 2 (.74) = 137 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT
EXIST. 4 BR DWELL. TO BE USED FOR ANY OTHER PURPOSE.
+ 80.4 TOP FNDN = 82.2' BOTTOM: 33.5 x 12.83 (.74) - 318 8, PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
+ 82. ,\+ 81.1 615 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
TOTAL: S.F. 455 GPD
8 0.6 USE (3) 500 GAL. LEACHING CHAMBERS (ACME OR INSPECTION BY BOARD OF HEALTH AND PERMISSION ❑BTAINED
FROM BOARD OF HEALTH.
EQUAL) WITH 4' STONE ALL AROUND 10. PUMP & REMOVE FAILED LEACH PIT
1.0 84,2 + 2.2 REMOVE ALL CONTAMINATED SOILS WITHIN 5' OF NEW LEACH FACILITY
8 F�
1. 0.9
00 �.
cbry 10$0,8 ,� CT /
N + ° x g0.$ �,, 1�0.6� -�z 2,4 LEGEND
TITLE+ 8 � �^ x LE5 SITE PLAN
PROPOSED SPOT ELEVATION OF
l� /80.6 / + 0 28 HAMSTEAD LANE
00 80.7 + 80.9 / / \�9 100x0 EXISTING SPOT ELEVATION IN THE TOWN OF:
$" HOLLY W / / MMAQUID BARNSTABLE
100PROPOSED CONTOUR+ .9 ( CU J
t` .7 /
�� I PAVED / oTH 7 � 100 EXISTING CONTOUR PREPARED FOR:
� \ 0.9 / DRIVE / + 95.7 ELROY ANDERSON
0.5 0� C+'1'�>•6 75
�6 20 0 20 40 6p
\ 6 A�F< 6 Q� 80.8 / 1 + 3 4 74 BOARD OF HEALTH -
NG MA SCALE: 1" _ NOVEMBER 13 2002
00 / \ APPROVED DATE 20 DATE:•E.
+ 71.9
off 506-362-4541
L�/ fox 506 362-9660
Of �N OF M
.9 down cape engineering, inc, ��Pl`ARNEAt�q`�ti oARNE H.
H. G O ALA
CIVIL ENGINEERS U OVA CIVIL
No.2 .18 oQ
LAND SURVEYORS
+ 77.8 /
02-35 > 939 rlai`n st, Yarmouth, no. 02675
ARNE H. OJALA, P. ':;`'� .L.S. .DATE
r,;
-Toe GF
ILL cJ All" I
G -
ST.
------- --- ------ _ _ Soh
73
olopl-
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HOJ2/Z. SCALE : � � C 7- � / V ------ (/F_ A? -7 SC49L � : / "= /O� /"1,9tiH0LE E�COUS 7-0
--o--- o—a---o -- prOf7oSec7 9rour�d Profile ---- /2" OF F'/ti/iSHEU GZF�D
---— F L O!n/
40 F?vC. O,e Crl7in, JmurT� �4:. �e4r f00� Cam" �T %8 - �2" GUlt�t~eQ S'for�E'-�
EQO,9 L. To SE PT!c �-
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D/ST Box t
/boo Gr9e- T/C 77,4NAc� .sherd sfor7�
D E T�
r� -7 0L LOG
cy;5norlser !n/!TtiIF-=$$ : IJ. jeqCUL l u er,� : �`•__ 1
M/,,1./in/C N
F ow ,E,9TE- GALS. DAY
•, TEST .�-lOL � #/ TEST
E-o r/C TA n-/k x /. 5 = �,. �• 8 _------ --✓--
`-`
� E F F• DEPTH '� .__
S. F. (2,OD) s /�, �
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C T! Y THAT THE B U/L D;N G T El- G E- P L_ F9 AJ
`' Z ! Pl2of�oSED On-1 THE- vn-/D FPS S
SH0&-./A/ OAJ 7- S PL
TO THE BU/� D ,`/�1G SE7=
B ?c? ,2 E Q Cn.ITS OF-• THE GU MM F9 U 1�
D F O Q: 7-F) A,,,,1
44
S N v tn/N DATE - tild v.
HINCKLEY
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y.�,q ,�2 /--7 o u T
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Pr- or)� _ f'f BOF� 2D O� HCFaL_TH
-- - - -- - - - exisf ! nc� cvnfovrs .5 / de = /`-' —
- - o --o --- o -- p/O �/pose CCU r7-fov S - C�