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HomeMy WebLinkAbout0026 HANSON LANE - Health s . 26 Hanson Lar..e0 - Barnstable A= 316 -.092 - J Commonwealth of Massachusetts �n Title 5 Official' Inspection. Form. . r Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �- 26 Hanson Laneck Property Address i1 Karen Davidson Owner Owner's Name information is Barnstable ✓ Ma' 02630 10-31-19 p`F required for every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information p2 on the computer, Brett Hickey use only the tab key to move your Name of Inspector cursor-do not B&B Excavation use the return Company Name key. . 374 Route 130 O Q Company Address Sandwich Ma 02563 City/Town State Zip Code rrxv (508)477-0653 S113747 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ❑0 Passes 2. ❑ Conditionally Passes 3.. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails oreamh+ureaW 9ren Nskm Brett Hickey o�: �^� �•�•�•� ���m.�..a•��s 10-31-19 O.:3019.11.0513:43:01 OM 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Hanson Lane Property Address Karen Davidson Owner Owner's Name information is Barnstable Ma 02630 10-31-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: The system was in working order at the time of inspection. 2) 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", "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): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts �m l.9 Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Hanson Lane Property Address Karen Davidson ` Owner Owner's Name information is Barnstable Ma 02630 10-31-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): S ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed. ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y .❑ W' ❑ 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): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain.below): - 3) 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. a. 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Hanson Lane v Property Address Karen Davidson Owner Owner's Name information is Barnstable Ma 02630 10-31-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ ' 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 b. 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. ❑ 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 asses if the well water analysis, performed at a DEP certified laboratory, for fecal Y r Y � rY 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. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No El a 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18 Commonwealth of Massachusetts ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Hanson.Lane v� Property Address Karen Davidson Owner Owner's Name information is Barnstable Ma 02630 10-31-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ El or liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool El El than depth in cesspool is less than 6"below invert or available volume is less than '/day flow ❑ E Required pumping more than 4 times in the last year NOT due to clogged or.' obstructed pipe(s). Number of times pumped: ❑ El 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. • ❑ 0 Any portion of a cesspool or privy is within'a Zone 1 of a public water supply well. r ❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0 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 2000 gpd- ❑ ❑ 10,000 gpd. 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. 5) 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply r ❑ ❑ 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 t5insp.doc•rev.7/26/2018 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Hanson Lane Property Address Karen Davidson Owner Owners Name information is Barnstable Ma 02630 10-31-19 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ❑ El Pumping information was provided by the owner, occupant, or Board of Health ❑ 0 Were any of the system components pumped out in the previous two weeks? ❑ El 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? Q ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ El Was the facility or dwelling inspected for signs of sewage back up? El ❑ Was the site inspected for signs of break out? El ❑ Were all system components, excluding the SAS, located on site? El ❑ 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? ❑ O 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: Q ❑ 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)] t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - ' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Hanson Lane - V Property Address Karen Davidson Owner Owner's Name information is Barnstable Ma' 02630 10-31-19 required for every page. City/Town 'State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: - 3 3 Number of bedrooms(design): Number of bedrooms(actual): 349/GPD DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): Description: 0 Number of current residents: Does residence have a garbage grinder? _ ❑ Yes El No Does residence have a water treatment unit? ❑ Yes No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes.FE] No Seasonal use? ❑ Yes [E No See below Water meter readings, if available (last 2 years usage (gpd)): Detail: a 2017- 10,000gallons 2018- 20,000gallons Sump pump? ❑ Yes ❑■ No May 2019. Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ` 26 Hanson Lane V Property Address Karen Davidson Owner Owner's Name information is Barnstable Ma 02630 10-31-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: NA 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: 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 below): 3. Pumping Records: . Source of information: Owner- date of last pump is unknown Was system pumped as part of the inspection? ❑ Yes M No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7Y26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts �v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Hanson Lane ,. w v� Property Address Karen Davidson Owner Owner's Name information is Barnstable Ma 02630 10-31-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) r 4. 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 a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ' ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: New SAS (2008) added to existing tank (1980) Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No 5. Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ❑■ 40 PVC ❑ other(explain): Town water, Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments I 26 Hanson Lane Property Address Karen Davidson Owner Owner's Name information is Barnstable Ma 02630 10-31-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 21 Depth below grade: 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 1 Dimensions: 000gallons 511 Sludge depth: 3111 Distance from top of sludge to bottom of outlet tee or baffle Orr Scum thickness NS Distance from top of scum to top of outlet tee or baffle NS Distance from bottom of scum to bottom of outlet tee or baffle measured How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The tank was in working order at the time of inspection. The tank is not in need of pumping at this time but should be pumped every two years for maintenance. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 ✓ c Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Hanson Lane V Property Address Karen Davidson Owner Owner's Name information is Barnstable Ma 02630 10-31-19 required for every page. City/Town State Zip Code Date of,lnspection D. System Information (cont.) f. 7. Grease Trap(locate on site plan): ` NA 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.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): NA Depth below grade: Material of construction: . ° r ❑ concrete '❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): J. Dimensions: Capacity: gallons Design Flow: gallons per day - t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Hanson Lane V� Property Address Karen Davidson Owner Owner's Name information is Barnstable Ma 02630 10-31-19 required for every page. City/Town State Zip Code Date of Inspection D.-System Information (cont.) 8. Tight or Holding Tank(cont.) 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 9. Distribution Box(if present must be opened) (locate on site plan): 0" 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.): The d-box was in working order at the time of inspection. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection 'Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Hanson Lane u— - Property Address Karen Davidson Owner Owner's Name information is required for every Barnstable Ma 02630 10-31-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. 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.): NA If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: ' Type: ❑ leaching pits number: t (2)500 gallon chambers leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: o ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Hanson Lane Property Address Karen Davidson Owner Owner's Name information is Barnstable Ma 02630 10-31-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The SAS was in working order at the time of inspection. Leaching chambers were dry when viewed with no evidence of past backup. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): NA 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.):' t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • 26 Hanson Lane w Property Address Karen Davidson Owner Owner's Name information is required for every Barnstable Ma 02630 10-31-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): , i NA Materials of construction: • Dimensions , Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): i l5insp.doc•rev.7/26/2018. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 26 Hanson Lane L Property Address Karen Davidson Owner Owner's Name information is Barnstable Ma 02630 10-31-19 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. 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 EV VAGE ASS SOWS MAI eFt " � ` " RR T-? R1.. 1i 'S TT Bc P-YC►P N+G3 .... d ' ..�„�.-rd. . Sepas,az43as�e �� '• !h1Cax teiaa<r djais+ 4,cix runiS, r,T Bz gt*'afl efte g P6c1tB tact Pnvate 1�S l pptr waif Am i ci�us pAcillcy(iFa"v. 119 CXIA a k, ti. aKr air wiailn !fees ofeectiuvg ?lsiy j Tti fsdgtufaindanrSi.eisdsusg "aci6axy(iEaxay.wwlassdsr•cxstwisihilx �oe1 Vie•at'te�wt+fx+�> 11#,ryr3 __.V__..�._. _....�^ ': >�trtuvrlY __ � _ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 26 Hanson Lane Property Address Karen Davidson Owner Owner's Name information is Barnstable Ma 02630 10-31-19 required for every page. City/Town State Zip Code Date of Inspection. D. System Information (cont.) ' 15. Site Exam: ,. Check Slope 0 Surface water ❑■ Check cellar i 1101 Shallow wells ' y NoGW@144" Estimated depth to high ground water: 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: 10-21-2008Date ❑ 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: A plan on file at the local Board of Health was used to determine high groundwater. z Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 f c , Commonwealth of Massachusetts 1. Title 5 Official Inspection Form la Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments 26 Hanson Lane Property Address Karen Davidson Owner Owner's Name information is re uired for eve Barnstable Ma 02630 10-31-19 4 every _ page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑■ A. Inspector Information: Complete all fields in this section. ❑■ B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ■❑ C. Inspection Summary: rY 1, 2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ❑■ D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 Commonwealthtof Massachusetts f Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Hanson Lane, Barnstable, MA 02630 Property Address = LUCY WATSON BAKER Owner Owner's Name information is MA 02630 09/19/2008 required for Barnstable every page. Cityrrow n State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Imp°"a"t A. General Information When filling out forms on the computer,use Inspector only the tab key 1. to move your Reid C. Ellis cursor-do not Name of Inspector ` use the return key. Ellis Brothers Const Co. Company Name 23 Enterprise Road P O Box 59 Company Address Yarmouth Port MA 02675 Citylrown state zip Code 508-362-6237 S121891 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the W 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. 1 am a DEP approved system inspector pursuant to Section 15.340 of Titre 5(310 CMR 15.000).The system: ❑ Passes ❑ Conditionally Passes. 2/Fails ❑ Needs Further Evaluation by the Local Approving Authority 01 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 ireport 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. ELLBROS INSPECTION 08 26 tianswr lane•031178 Title 5 Offidal lnspeclim Forth.Subsurface Sewage Disposal System•Page 1 of 15 Commonwealth:of Massachusetts Title 5 official Inspection Form' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Hanson Lane, Barnstable, MA 02630 Property Address LUCY WATSON BAKER Owner Owners Name information is required for Barnstable MA 02630 09/19/2008 every page. Cityrrown State Zip code Date of Inspection B. Certification (cunt.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: A/V ❑ 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: B) System Conditionally Passes: ❑ One or more system components as descrit ed in the"Conditional Pass"section need to be replaced or repaired.The system, upon coff pletion of the replacement or repair, as approved by the Board of Health,will pass. Answer yes, no or not determined(Y. N,ND)in he❑for the followirig statements. If"not determined,"please explain. ❑ The septic tank is metal and over 20 years c Id*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infi tration or exfiltration or tank failure is imminent. System will pass inspection if the existing tai ik 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 les than 20 years old is available. ND Explain: Observation Hof sewage backup or break out r high static water level in the distribution box due ❑ 9 P 9 to broken or obstructed pipe(s)or due to a b oken,settled or uneven distribution box. System will pass inspection if(with approval of Board ofHealth): ❑ broken pipe(s)are replaced ❑ obstruction is removed ELLBROS INSPECTION 08 26 hanson lare•MMS We 5 Official loon Form:Surface SeuaW Disposal System•Page 2 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Hanson Lane, Barnstable, MA 02630 Property Address LUCY WATSON BAKER Owner Owner's Name required for is Barnstable MA 02630 09/19/2008 required for every page. cityrrown State zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cunt): ❑ distribution box is leveled or repla 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 approv, I of the Board of Health): ❑ broken pipe(s)are replaced R ❑ obstruction is removed ND Explain: i . i C) Further Evaluation is Required by the and of Health: ElConditions exist which require further ev uation by the Board of Health in order to determine if the system is_failing to protect public heal , safety or the environment 1. System will pass unless Board of 1H aalth 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 f of a surface water ❑ Cesspool or privy is within 50 fe of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board o Health(and Public Water Supplier,if any) determines that the system is functioi iing in a manner that protects the public health, safety and environment: ❑ ' The system has a septic tank an I soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or trib ry to a surface water supply. ❑ The system has a septic tank a SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank ar J SAS and the SAS is within 50 feet of a private water supply well. ELLBROS INSPECTION 08 26 hanson lane-0301 Title 5 Offibal UIsPediun poem:SOMAIce Sewage Disposal System-Page 3 of 15 f Commonwealth'of Massachusetts Title 5 Official Inspection Form., Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ' 26 Hanson Lane, Barnstable,MA 02630 Property Address LUCY WATSON BAKER Owner Owner's Name information is required for Barnstable MA 02630 09/19/2008 every page. City/Town State Zip Code Date of Insp ection B. Certification (corn.) C) Further Evaluation is Required by the Boa of Health(cont.): ❑ The system has a septic tank and SAS an 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 analysi , performed at a DEP certified laboratory,for coliform bacteria indicates absent and the presence of immonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure Niteria 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 intofacility or system component due to overloaded or clogged SAS or cesspool ElDischarge 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%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. ELLBROS INSPECTION 08 26 hanson lane•03108 TWO 5 Ofiaal Inspedm Font SWSU face Sewage OWPOSGl System•Page 4 of 15 Commonwealth'of Massachusetts J.- Title 5 Official Inspection Form'. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Hanson Lane, Barnstable, MA 02630 Property Address LUCY WATSON BAKER Owner Owner's Name information IsBarnstable MA 02630 09/19/2008 required for every page. cityfrown state Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems(cunt): 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 Boa of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large syste a 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" o"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 El ❑ the system is located in a nitro en sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zo a 11 of a public water supply well If you have answered"yes"to any question in Secti-1 1E 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 ELLBROS INSPECTION 08 28 hansom lane•03MB Tim 5 Offidal hupedw Fomr Sut>sd"Sewage Disposal System•Page 5 of 15 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments y 26 Hanson Lane, Barnstable, MA 02630 Property Address LUCY WATSON BAKER Owner owner's Name information is required for Barnstable MA 02630 09/19/2008 every page. Citylrown State Zip code Date of Inspection C. Checklist Check if the following have been done.You must indicate°yes"or"nor 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? El this 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 components,Muding 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? y ❑ 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)] EU BROS INSPECTION 08 26 hw=n W•03M Title 5 Otrmal Inspectim Fa r-Svavafem Sewrae Disprsal System'Page 6 Of 15 Commonwealth Iof Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments y 26 Hanson Lane, Barnstable, MA 02630 Property Address LUCY WATSON BAKER Owner Owner's Name information is required for Barnstable MA 02630 09/19/2008 every page. cityrrown State Zip Code Date of Inspection D. System Information Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): ..� DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): ` c Number of current residents. Does residence have a garbage grinder? ❑ Yes ;/No No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ -Yes Laundry system inspected? ❑ Yes No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): Sump pump? ❑ Yes EV No T L- Last date of occupancy: Date CommerciaUindustrial Flow Conditions: /® Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons perday(gpd) Basis of design flow(seats/persons/sq.fL, etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 syst m? ❑ Yes El No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): ELLBROS INSPECTION 08 26 hanson lane-03/08 Title 5 Official knPacdon Fomc SubsuRaoe Sewage Disposal System-Page 7 of 15 1 � u Commonwealth of Massachusetts i t i le 5 Official Inspection Form Title p Subsurface Sewage;Disposal System Form-Plot for Voluntary Assessments 26 Hanson Lane, Barnstable, MA 02630 ' Property Address LUCY WATSON BAKER Owner Owner's Name information is Barnstable MA 02630 09/19/2008 required for state Zip Code Date of Inspection every page- City/Town D. System Information (cont.) General Information Pumping Records: Source of information: Was stem um ed as art of the inspection? ❑ Yes L/ No W y P P P If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of yytem: 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/Altemative 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 E] Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): r J known and source of information: Approximate age of all components,date installed(if ) C r Were sewage odors detected whr amv'ing at the site? ❑ Yes No Tma 5 o(fi to kwpecUm Fmm Subsurftw SeW39B DOPOW Ste Pa98 8 of 15 ELLBROS INSPECTION 0826It0dw WW 03 08 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Usposal System Form-Not for Voluntary Assessments 26 Hanson Lane, Barnstable, MA 02630 Property Address LUCY WATSON BAKER Owner Owner's Name information is Barnstable MA 02630 09/19/2008 required for ate Zip Code Date of Inspection every page. cityrrown D. System Information (cunt.) Building Sewer(locate on site plan): Depth below grade: ..feet , Material of construction: ❑cast iron 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): 94 Depth below grade: feet 7ieal ofconstruction: ncrete ❑ 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 E] No ---------- oo Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle C� 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 How were dimensions determined? ELLBROS INSPECTION o8 26 Timm i taro•03fW Title 5 Orfiaal Fonm Substafaoe Sewage Disposal Sign•Page 9 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage`Disposal System Form-Not for Voluntary Assessments 26 Hanson Lane, Barnstable, MA 02630 Property Address LUCY WATSON BAKER Owner Owner's Name information Barnstable MA 02630 09/19/2008 eau ge. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): II Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal El fibei glass ❑polyethylene ❑other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or ffle Distance from bottom of scum to bottom of outlet I ee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet E nd outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence o leakage,etc.): Tight or Holding Tank(tank must be pumped at ti o inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete Elmetal ❑fiberg ss Elpolyethylene . ❑other(explain): ELlBROS INSPECTION 26 hansom lane•03/08 Title 5 Official In am:Inspection Fo Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . y 26 Hanson Lane, Barnstable, MA 02630 Property Address LUCY WATSON BAKER Owner Owners Name information is required for Barnstable MA - 02630 09/1912008. i every page. Cityrrown State Zip Code Date of Inspection All, D. System Information (cone.) Tight or Holding Tank(cunt) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present ❑ Yes ❑ No Alarm level: Alarm in working order. ElYes ❑ No Date of last pumping: Dam Comments(condition of alarm and float sw' rhes, etc.): / Attach copy of current pumping contract( ). Is copy attached? El Yes El No /� Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert . � Comments(noteif box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or-out of bo), etc.): 4 Pump Chamber{locate on site.plan): Pumps in working order. ElYes ❑ No Alarms in working order. ❑ Yes ❑ No ELLBROS INSPECTION 08 26 hanson lane•03MB Title 5 Official h Wect on Form:Sum Sewage Disposel System-Page 11 of 15 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage.Disposal System Form-Not for Voluntary Assessments 26 Hanson Lane, Barnstable, MA 02630 Property Address LUCY WATSON BAKER Owner Owner's Name information is Barnstable MA 02630 09/19/2008 required for every page. Cityrrown State .Zip Code Date of Inspection D. System Information (corn.) Comments(note condition of pump chamber, ndition of pumps and appurtenances, etc.): Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located, explain why: Type: leaching pits number: ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: leashing fields number, dimensions: ❑ overflow cesspool. number. ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation, etc.): �--- - • 4-; 9-%eW 6,3 < Wr b4-,45 -b-e" att'-V- "-11�7-t,75P -tFZI, OvIA _rJAI-S ELLBROS INSPECTION 08 26 hanson lane-03108 Title 5 offidal Inspection Farm:SuSwrface Sewage Disposal System-Page 12 of 15 Commonwealth of Massachusetts j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Hanson Lane, Barnstable, MA 02630 Property Address LUCY WATSON BAKER Owner Owner's Name information is required for Barnstable MA 02630 09/19/2008 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cunt.) Cesspools(cesspool must be pumped as par 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 hyd ulic 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 hy Jraulic failure, level of ponding,condition of vegetation, etc.): ELLBROS INSPECTION 08 26 hwism tans.03= Title 5 offickd hspeaion Fom Wm face Sewage Disposal System.Page 13 of 15 Commonwealth!of Massachusetts j Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Hanson Lane, Bamstable, MA 02630 Property Address LUCY WATSON BAKER Owner Owner's Name information is required for Barnstable MA 02630 09/19/2008 every page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) Site Exam: ❑ Check Slope ❑ Surface water ✓ ^ ❑ Check cellar. ❑ Shallow wells -f-a Estimated depth to high ground water. 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: installers- attach documentation' local excavators,Checked with o Accessed USGS database-.explain: La L! You must describe how you established the high ground water elevation: U �� . - 05 tom 7 rl ELLBROS INSPECTION 08 26 hanson lane•OW08 Title 5 Offiaal Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15 t 1! Commonwealth of Massachusetts Title---5 Official Inspection Form .� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Hanson Lane, Barnstable MA 02630 Property Address LUCY WATSON BAKER Owner Owner's Name information is Barnstable MA 02630 09/19/2008 required for State Zip Code Date of Inspection every page. City/Tovvn _ D. System Information (coat.) 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. Ab -- w c.aa e� ELLBROS INSPECTION OFl Z61�rrson lane•03l08 Tithe 5 Ofiaal trapedion Form:SubstuFBoe Sewage Disposal System•Page 14 of 15 1 l Commonwealth of Massachuseft i Title 5 Official 'inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 26 Hanson Lane, Barnstable,MA 02630 Property Address LUCY WATSON BAKER Owner owrtees Name information is Barnstable MA 02630 09/19/2008 required for every page. C41Town State Zip Code Date of Inspection Inspection results must be submitted on this form.inspection forms may not be altered in any way. Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Reid C. Ellis cursor-do not Name of Inspector use the return key. Ellis Brothers Const.Co. Company Name V 23 Enterprise Road, P.Q.Box 59, Company Address Yarmouth Port MA 02675 Cityfrown state Zip Code 508-362-6237 S121891 Telephone Number License Number B. Certification I certify that 1 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'15.00%.The system: ❑ Passes ❑ Conditionally Passes 2/Fails ❑ Needs Further Evaluation by the Local Approving Authority 1 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 greaten 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. FLLBROS INSPECTION 08 26 hanson lane.03MO Title 5 Official kupection Form:Subsurface Sewage Disposal System-Page 1 of 15 i TOWN OF BARNSTABLE OCATION Anil-I SOJ1 L,n i SEWAGE# �� VILLAGE�,, � V- SSESSOR�'SS�MAP&PARCELp INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY:(type) �/r?pr ���� (size) NO.OF BEDROOMS 2 DJ OWNER L-" C Q 4V SC_,A PERMIT DATE: 41/09 COMPLIANCE DATE: Separation Distance Xetween 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 f� y. -A ; l No. ,. /j/p/ - :e" 61�Fee THE COMMO WE T-VH/IOF MASSACHUSET© Entered in computer. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes Zippfication for bisposal Opsteru Construction Permit Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. N y� Owner's Name A ress and Tel Nq� d-G Assessor's Map/Parcel �! 7,�17 _u c C,*K vv►f✓ y Installer's Name,Address,and Tel.No. Jll 2 SQ.wF Designer's Name,Address,and Tel.No. 9 fyli44. zV S i ZOO st!S=' CO S �• r w s� � d jw (JdGri0 vo fP✓li Ape se Type of Building: Dwelling No.of Bedrooms Lot Size C( (9 v 7 sq.-ft. Garbage Grinder( ) Other Type of Building ����s.� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided ,�7 ! gpd Plan Date 0 C, t Number of sheets Revision Date Title Size of Septic Tank l / 1 Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) /j/e k" S,/P 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 Board of al one Date d Application Approved by Date Application Disapproved by Date for the following reasons Permit No. "' Date Issued F ,.;.�.,.....>w..--.rsr...w.era.,^^+^:wWx+n✓�M.ti.i�.-.y:..+t.,;y,,.vn.�-..,,.,.:"'.._._...--.-,...-�__ _....-..�T \C'� - " ��/V k�. r ,r -..'i..r a1r-,+.-. '-�..'L' .__ � f}y No. .. � � L D elf V19 Fee : i THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplicatlott• for-Misposal Opstettt Construction j9ermit �'• Application for a Permit to Construct( ) Re air( ) Upgrade Abandon ❑Complete System Individual Components PPS ( ) ( ) P Y ❑ p Location Address or Lot No. a 4 0 �.- Owner's Name,A dress,and Tel.No. / Q Assessor's Map/Parcel ��� / � 4?4 G(P�1 ' / ��4 h (;( Installe\s Name,Address,and Tel.No. S']1 S/Q 1164 --(/ Designer's Name,Address,and Tel.No. 9,7 fyVd,� �d/ N9b2 Ci0 Type of Building: ,7 Dwelling No.of Bedrooms Lot Size C/J, C� J17 sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 2-70 gpd Design flow provided —r-,�/ e.:r gpd Plan Date G C (31 �{ Number of sheets / Revision Date Title i. Size of Septic Tank r✓J el Type of S.A.S. t Description of Soil Nature of Repairs or Alterations(Answer when applicable) /��C� 4J `S /('has ��Y/C A S-y C --,ri•,.; J ' 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 Board of altk�. �&ed i % / Date 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 CERTIFY,that the On-site Sewage 'Diisposal�system Constructed( ) Repaired(�Q Upgraded( ), Abando 'd( )by C-� Y ( S at 62 LVE, ,/M /V5 I /(has been constructed in accordance 1 t f T with the provisions of Title 5�d the �for nD�is?osaf�System Construction Permit-No -- daatt�ed�} �-^���, j ! j _1-�•/ 1.09 V I / Designer l /Y GYU7 //j� � I Installer #bedrooms \J Approved desi . flow 1 /Y gpd n �. j The issuance of this permit shall rfot be°construed as a guarantee that the system willfG�r►fti�ofnj as designed. Date / �/l 1196 Inspector �`V,�f ' '�/r � ) 1 ;o i,j�� Fee No. �"" r (�f THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH§DIVISION-BARNSTABLE,MASSACHUSETTS Oisoosaf *pstrm Construction Permit Permission is hereby gr to toCons"` trupt(� ) R,epair( / Upg;ade ) A/liando p ) System located at /' ( /1!I//nl C�' �V/ +(/� I !f >" rrY. and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructiontmust ,e dompK7, d,within three years of the date of this permit. Date ( Approved by /- J ._-RQM,-''dcwn cape engineering inc FAX NO. : 15083629380 Dec. 01 2008 12:42PM P1 zF•s Town of Barnstable Regulatory Services f E ice= mass. Plibife Heafh Division . - P `. T'i�sa� as i'�1e.1r4e�aanlDitn°eelarn r' 200 MaJ.n,sijrcet,llyamrfi>,Nlt A.0265,01 ! OfiicC 50 ,R52-�(i44 F;jx: 508.790-C3ij4 Ik�. nsta:➢.leer & Desin er Ccrtillea>tion Form g d�� S > e zEtliS(, ®�lltf9., ��6'aD � ��&'�ffi�� �e� �50�'@SUU1�9W �!➢°2@��11� e`4&��'l. 1 9 Inqt Her Sddrem. :S'��'(/��- N�f• On �• �I.: .. ...-.,-flu... L ��,C/I/ I _ was is�., zd.a permit to li Stahl a Q.r crate) (installer) septic system at t_la_Vq kit hased on a.design drawn by t � (,:.dd.icss) C k z v�✓L e l�lP>r�I+�t� dcateC1 i - T certi 1y that: the Se tics stem rcfe7•enced above was it�sCalled slzbstalitia.11y �ccl�rili.nK to' the design, which may include ajnin.o.r approved.changes sinch ,is lateral reloca ho li crf the distributions box Euid/or septic tank, I certify that: the septic system referellCe i above was installed with major changes (i.e. grcaM'than 10' lateral relocati.00n.of the SAS oT auy vert.icaI relocation !rf'any component i3f the sep!:i.c system) but in accordance wilb. State cYr Local Regulation.s. .l'laii revision or £' corti'(ied as-buflu by designer to follow. F �f; 3f OF Mgs�c i � ' DANIELA, y�N A ' /r OJAI A `�.'s ignatbare) / CIVIL �No,46502o �GISTF- , I s d kr esJgn.cr's Signaturc) (hfti:u l tiigner's Sta un pert:) _l.1ETURN TO TIARNST.A_R..E PUBLIC ➢➢EAT,T11 DIVISION. C I.Yi i Li�A'FT,�C?3C (;2Lt .*Rl.' ANi d"'E WT.lj, NOT BIR N,8,51j"E ) UNTIL BOTH, TMS IFOICW AND AS-BUILT CARD ARE 1,*r R ff;C'E,J.VE D RY TIff,BARNSTABLE I'U BLIC HEnr..TH DMMON. TMISK YOU. 0: byW:.i.il'ilSci�l.rc/TZrs'sesirrl;cr�.i(:icr�!.iun.J urrn i-1G-o!,c!oc + i ' t 2`! P G-EC -2 Ail 9' I r q 65 220• 1-tvaaration of Plans.and Jpecti]caau � ri kl• ,• , ,� •, r< r - � r Tnd plans and specuflcations4or every on-site system shall be prepared as follows: (1) •Every system shall be designed by a Massachusetts Rcgiszcied Professional Engineer or a'Massacfiuetts Registered Sanita..-ian provided that such Sanuarian shall nut-design a. system desig'rfed to discharge more than 2,000 gallons per day pursuant to 310 CMR 15.203: . Any other agent of the o�cncr.may prepare-plans for the repair of a system-designed,to discharge not mort than than•2,000 gallons per day pursuant to 310 CMR 15203'provided they arc reviewdd by:a Massachusetts Registered Sanitarian and,approved by the.approving`� p authonr; / .(2). .Evcry.•plan submitted for approval must-be dated and bear the stamp and signatu= of: -the designer; . • (3J -Every plan'for a new systcrn or plan for the upgrade or expansion of an c istirig:sytterii' which requires a variance to a property line setback distance;•must;also reference--a plan which bears the stamp and signature of a Mzssachd3c Li tts- censed.Land Surveyor in accordance with M.b.L. c: 112, §:81D; (4) Every plan for a system shall be of suitable sca o'(one inch.40 feet or fewer for Bloc plans and one-inch—20 feet or fewer for details of system.Gomponenu). fnd.shall includ . . depiction of: (a) the legal boundaries of the facility to be served: -(b) the holder and location of any easements appurtenant to or which could impact th stem; _ (c) the location of the all dwdlling(s)or-buildi:rg(s)existing and proposed on the facility and idcnrifieati¢ri of those to'be served by the system; (d) =the'itscarion of ezistirig or proposed irtper�ious••areas, irldtrhing:driveways and .parking areas - (e) location and dimensions of•tho sgstam (including reserve are •:. -• (f)• sxst`m design calculations,including design daily sewage flow, septic rank capacity (required and provided); soil absorption system capacity (required and provided); and - whether system is designed for garbage grinder; ( ) North arrow and existing and proposed contours; (h): Iodation of deep'ob'servatien Bole tests including the date of test,.odsting grade elevations marked on cacti test, and the names of the represcntavc of the approving authority and soil evaluator, (i) location and results of percolation-tests including thd.aate-of test-and tho naives of -the,representative of the approving authority and soil-evaluator, name trio certification number of the Soil Evaluator of record; (k) location n evcry'Watcr supply,public and private, I. within 400 feet of the Proposed system location in the case of surface water _ supplies and gravel-packed public water supply wells, 2. within 2.50 feet of the proposed system location in the case;of C,ibular public water supply wells, and 3. within 150 feet•of the Proposed'system Iocation in the case of private water VZ1 supply wells: 1) location of any sri<face waters of the Commanwealth.'rivers, bordezing..vegttated , wetlands, salt marshes, inland or coastal banks, regulatory fioodwaq, vslocizy zone, surface water supplies, tributaries to surface_watcr supplies,certified vtsrnalpools,private :' G water supplies or-suction lines, gravel packed-or tubular public water 3trpply was, / subsurface drains, Ieaching catch basins, or dry wells, and the location of any rtitrogen. / sensitive area identified in 310 C1vLR52I5 within which portions of the proposed stem and located. (m) location of water lines and.other subsurface•utilities on the•facili ty; (n) observed and adjusted ground-water elevation in the vicinity of the system; o) a.complete profile of the system; . p (p) a note on the plan listing all kariances to the provisions of 310 CIvIR 15.000 sought in canjurtction with the plan; (q) . the location and elevation of one bcrchmark.Within 50 to•75 feet of the facility 7 which is not sabjcct to d>slocadon.or;lost.d uring canssuctioii'ori'the' facility';-' (r) when dosing is proposed, complete design"and"Sper.ficatioa of the.dosing systera proposed including.but tot lirnited to dosing,charnber capacity (required and.proyided),'- s ump curves and.specifications, number s f d'osinD cycles and depth per cycle; s) when a RcciTculatisg Sand Filter or equivalent alternative technology is required or oposed, a complem plan and specification for the syste:7,including a hydraulic profile; (t) a locus plan,to show the location of the facility including the nearest existing strec chc street nu"Mbcr and lot num?rcr, if any, of the facility. and v) the material of construcd.dn.and the Speci£ca ions of the system. down cape engineering, inc. SIEVE SOILS ANALYSIS 08-253 Prchlik.xlsx DATE OF REPORT: 10/22/08 JOB : GRAIN SIZE ANALYSIS-SIEVE TEST SITE: 26 Hanson Lane, Barnstable, MA . LOCATION: DCE TESTHOLE icy/ulc SIEVE ANALYSIS Weight Sample(Grams): 378 SIZE :WEIGHT RETAINED ; % RETAINED : % PASSED ------------- sum--- ------ •---------------o-------- --- ---o ` 1" 0.0: 0.0%: 100.0% --------•• ----O.-A----------- - 0%----------1-00.0% ----- - 1/2" 0.0: 0.0%, 100.0% ------------- --•------------------r------- - ----- 0 0 0.0% ,---- , 100.0% #4 0.0: 0.0%: 100.0% ----------------- #10 17.2: 4.6%: -------------- -----.-------_-------- 4------------------•------------------ #20 96.7: 74.4% #40 261.8: 69.3%; 30.7% ______________f......-......---••- -------Y---_-__Y__-__-----f----T--.--------.1 #50 319.5: 84.5%; 15.5% -------------r--------------------------•-------------------r------------------ #80 ; 362.7:, 96.0%: 4.0% #100--------�-.- - 368$a----------97 6% --------------4— #200 376.0; 99.5%: 0.5% PAN: 378.0: 100.0%: 0.0% --------------r--------------------------T------------------------------------- - SAMPLE: 378.0; . NOTE` TEST ON PASSING#4 ONLY, 6% RETAINED ON #4 <45% O.K. RESULTS: SOIL CLASSIFIED AS AASHTO A-1-b (GRANULAR, SAND) (UNCOMPACTED) PERCENTAGE OF MATERIAL PASSING#4 SIEVE MEETS #4 100% (TEST ONLY MATERIAL PASSING#4)„ #50 10%-100% .� #100 0%-20% pKpOF Mggss9 #200 0%-5% wp�� DANIEL REQUIREMENT FOR"FILL" IN TITLE 5. a O tAIA - <5% PASSING#200 SIEVE CIVIC a No.46502 RESULTS: PERMEABLE MATERIAL-CLASS 1 <2 MINJIN. MATERIAL! °� c STe NONCOMPACTED n! SOIL DESCRIPTION: MED SAND,W/GRAVEL / TOWN OF BARNSTABLE LOCATION � h �� SEWAGE# VILLAGE 0%fnSk- bl-( ASSESSOR'S MAP&PARCEL rtt-,5 arm 3&aGd 3) INSTALLERS NAME&.PHONE NO. 4 �nSJ' SEPTIC TANK CAPACITYGf LEACHING FACILITY.(type) ize) NO.OF BEDROOMS OWNER PERMIT DATE: 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 within 300 feet of leaching facility) Feet FURNISHED BY C. `e Ar. t I 9 TOWN OF BARNSTABLE LOCATION 14MSQr, /AAL SEWAGE# .,VILLAGE R&A SbALJ4 ASSESSOR'S MAP&PARCEL INSTALLERS NAME&PHONE NO. SEPTIC TANK CAPACITY � 19 LEACHING FACILITY:(type) RT' (size) MIT NO.OF BEDROOMS 3 OWNER PERMIT DATE: 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 within 300 feet of leaching facility) / Feet FURNISHED BY r/► SPL4, ipn -J7 Core D/G IA 04k a A �3 3L ayb 3 Y 3 31 3S` �„N l ��z :�a8 ToWn of Barnstable P# Department of Regulatory Services ' Public Health Division Date / IBLARNFrAB �. MAS s 200 Main Street,Hyannis MA 02601 sa»• �� Y " • �Vx1�0 00 Date Scheduled Time Fee Pd. Soil Suitability Assessment for Sewage, ispos io � Performed By: Witnessed By: 1 ✓/ ' LOCATION & GENERAL INFOIt1NIATIOG� 1' Location Address Owner's Name 0 �` GL✓ /�/J �/� Address Assessor's Map/Parcel: /a Y Engineer's Name Q W►� NEW CONSTRUCTION REPAIR ` Telephone# ((� 3 k 6(� � Land Use A I Slopes(%) V— Surface Stones Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well L J_ft Drainage Way ft Property Line / ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of test holes&perc tests,locate wetlands�n proximity to holes) Uj N W ��+ ,r Parent material(geologic) l�a'�/° l�/"f Depth to Bedrock Depth to Groundwater: Standing Water in Hole: °Weeping IYout Plt Pnee i" Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL HIGH WATER TABLE Method Used: �n Depth Observed standing in obs.hole: _In, Depth 105ai101010es: T Depth to weeping from side of obs.hole: ___ .__,a In, aroundwuter Adjustment,,,. ...,ft. Index Well# Reading Date: Index Well level Adl.factor _ t Adj.droundwater Level PERCOLATION TEST Do Time Observation SZ iV 'Time'at h" Hole# Depth of Perc Time at6" Stan Pre-soak Time @ _ Time(9"•6") End Pre-soak Rate Min./Inch , Site.Failed: Additional Testing Needed(YIN) Site Suitability Assessment: Site Passed y` Original: Public Health Division Observation Hole Data To Be Completed on Back------------ ***If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Conservation Division at least one (1) week prior to beginning. QAS EPTIC\PERCFORM.DOc DEEP.OBSERVATION HOLE LOG Hole# Dcpth from Soil Horizon Soil Texture Surface(in.) ` +'•. Soil Color Soil Other (USDA) (Munsell) Mottling (Structure,Stones;Boulders, Co istenc ravel � Z O DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Other Surface in.) Soil Color Soil (USDA) (Munsell) Mottling (Structure,Stones,Boulders. Consis e c %G a el 3 • x, ' C,1 z 4 f3 DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture '"---- Surface ' Soil Color Soil Other (USDA} (Munsell) Mottling (Structure,Stones,Boulders. Co !Ste c O v DEEP OBSERVATION HOLE LO Hole# Depth from Soil Horizon Soil Texture Surface(in.) Soil Color Soil Other (USDA) (Munsell) gttltn g (Structure,Stones;Boulders. Consi t ncv.%Gray I Flood Insurance Rate Man• p� Above 500 year flood boundary No_ Yes Within 500 year boundary No Yes Within 100 year flood boundary No Yes 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? S If not, what is the depth of naturally occurring pervi s material? Certification I certify that on Z (date)I have passed the soil evaluator examination approved by the Department of Envir nm ntal Protection and that the above analysis was performed by me consistent with the ieyuired trai ing,expertis an experience d scribed in 310 CMR 15.017. Signature 1P Date Q:ISEPTICU'BRCFORM.DOC I I I b D C� AS 84- ,3 , s 1.59..c. %A •49AC 4eA4c 8z ► dlA go �9 v at I.,%%� g w Ac . 80-1 44s �A I.03 Ac- ° � �`'°c s�—off►� o C vR°H i °o ® ot,e 1,54AC ^ W _ mac TS 044 .qsoa,�q Aga®.•,* � O / 80-4 10 Ly c O N ZP 1.01 d�c. 1 80-5 ^ 8%AC RY . I.00AC � y •O14C- m ♦1 e\ w ask 1.01►c. 1 so-<oor- 149 . l0 oo&.0 b � LoIIaC. n z � ei d .�tec N\'6 o 80-7 �I Naoh Iir o ^ K Y t J ,O1 lG o S .00 aC 24 J Bil r- � LC � , 4 I S D¢Iw esni ��7� _ ►C o 66AO J. 9c 80-9 - �C. O . N 8t►G el►C . I r 89 0 - d h J 32 t � 3 ► a I 891.01 O ® 1 .i Ile QS 10 Z D ��{ v 1.00Aaonsi, - a C q COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE-OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION q _NX : OA� , TITLE 5 OFFICIAL INSPECTION FORM NOT FOR'VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A . CERTIFICATION Property Address: 26 Hanson Lane Barnstable, MA 02630 Owner's Name:.. Wayne&Pat Dunham Owner's Address: 17 Whittier Avenue Waltham,MA 02154 . M Q 3� l9 Q Date of Inspection: August 13, 2007 Name of Inspector: (Please Print) James M.Fond Company Name: James M. Ford Mailing Address: . P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT 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 15.00%. The system; ✓ Passes ' nditionally Passes eds Further Evaluation by the Local Approving Atlth)rity ils. Inspector's Signature: Date: August 20 2 07 The system inspector shall subs ' a copy o this inspection report to the Approving Authority(Boar 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 systein owner_shall submit the report to the.appropriate regional office of the r.and copies sent to the buyer,if'applicable,and the approving DEP. The original should be sent to the.systetn,owne authority. t Notes and Comments ****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. Title 5 Inspection Form 6/15/2000 page.1 Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS . SU BSURFACE RFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 26 Hanson Lane Barnstable; MA Owner: Wavne&Pat DunhariT Date of Inspection: Aui ust 13 2007 Inspection Summary: Check AB,C,D or E/ALWAYS complete all of Section D A. System Passes: ✓ 1 have not found any infonnation which indicates that any of the failure criteria described in 310 CMR 15.303 of 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.replacefnent or repair,as approved by the Board of Health,will pass. Answer yes,no or not detennined(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 thai the tank is less 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 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: - 2 'Page 3 of 11 " OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS, SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 26 Hanson Lane Barnstable, MA Owner: Wayne&Pat Dunham Date of Inspection:. August 13 2007 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 ,y 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. r The system has a septic tank and SAS and the SAS is within a Zone Lof apublic 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 aseptic tank and SAS and'the SAS is less than:100 feet but 50 feet:or more from a r private water supply well**.. Methodu`sed to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory'.for coliforin bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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: 3. Page 4 of 11 OFFICIAL INSPECTION FORM"-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSALSYSTEM INSPECTION;FORM -PART.A CERTIFICATION (continued) Property Address: 26 Hanson Lane 5 Barnstable, MA Owner: v Wa ne&Pat D unhmn Date of Inspection: August 13, 2007 D. System Failure Criteria applicable to'all systems: You must indicate either"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 effluentto 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 ✓ Required pumping more than 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. ✓ 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility 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.] - No (Yes/No)The system fails. I have determined thaf one or more of the above failure criteria exist as described in 3 i0 CMR 15.303,therefore the system fails. The.system owner should contact theBoard•of Health to deterinine what will be necessary to correct the failure., E. Large: System: To be considered:a large system the system must serve a facility with a,design flow of 10,000gpd to 15,000 gpd•. You must indicate either"yes"or"no"to each of the following: (The following criteriwapply to large systems-in addition to the criteria above) 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 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 shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office,of the Department. 4�. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 26 Hanson Lane Barnstable, MA Owner: Wayne&Pat Dunham Date of Inspection: August 13, 2007 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 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? Was the facility owner(and occupants if different frorn 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: Yes No ✓ _ 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(3)(b)]. 5 f Page.6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -PART C SYSTEM INFORMATION Property Address: 26 Hanson Lane Barnstable, MA Owner: Wayne&Pat Dunham Date of Inspection: August 13. 2007 FLOW CONDITIONS' RESIDENTIAL 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: 0 Does residence have a garbage grinder(yes or no): n1a Is laundry on a separate sewagesystem(yes or no) n/d [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter-readings, if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy:. Unknown COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Qpd: . Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):. Industrial waste holding tank present(yes or no) Non-sanitary waste discharged to the Title 5 system(yes or no): v Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Unavailable Was.system pumped as part of the inspection(yes or no): 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 infonnation: Installed on 311.7181 -per as built card Were sewage odors detected when arriving at the site(yes or no) No 6 li ,3 Page 7 of 11 .. OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION;FORM - ,PART C SYSTEM INFORMATI.ON (continued) Property Address: 26 Hansoh Lane *: Barnstable. MA. ' Owner: Wayne&Pat Dunham Date of Inspection: August 13; 2007 xi BUILDING SEWER(locate on site plan) . Depth below grade: , Materials of construction:,._cast iron _40 PVC' other(explain) Distance from private water supply well or suction line ; Comments (on,condition ofjoints,venting,evidence of leakage,etc.): ' SEPTIC TANK: ✓ (locate on site plan) 8.. Depth below.grade: 20„ * - Material of construction: ✓ .concrete _metal =fiberglass. : polyethylene other(explain).'- If tank is metal list age:, Is age confinnedby a Certificate of Compliance(yes or no): -(attach a copy of certificate) Dimensions: 1000 gal: Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: "' 30" " Scum thickness: 2" Distance from top of scum to top of outlet tee or:tbaffle: 6" r Distance from bottom of scum to bottom of outlet tee or baffle: 10 , ` How were dimensions detennined:' -Measuring stick- Comments(on pumping reconnnendations,.inletand,outlet tee or baffle condition;structural.integrity,liquid levels as related to outlet invert;evidence of leakage,etc.). Cement tees were present. The liguid level was even with the:outlet invert. There did not appear to be ank signs of leakage. GREASE TRAP: .None (locate on site plan) Depthbelow grade. Material of construction: =concrete _metal _fiberglass ". polyethylene _other (explain): Dimensions: , - Scum thickness: Distance'froinaop of scum to top of outlet tee or baffle'A .#. Distance;from bottoin of scum to bottom of outlet tee.or`baffle:: Date of last pumping: Comments(on pumping recommendations;inlet and outlet tee or baffle condition,structural integrity,liquid levels t as related to:outlet invert,evidence of leakage,etc,): 3 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONFORM PART C SYSTEM.INFORMATION(continued) . Property Address: 26 Hanson Lane { Barnstable, MA Owner: Wayne&Pat Dunham Date of Inspection: August 13, 2007. TIGHT or HOLDING TANK: None (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/day Alann present(yes or no): Alarm level: Alarm in working order(yes or.no): _ Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Even 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.): The D-box was normal. No solids were present. PUMP CHAMBER: None (locate on site plan) Pumps in working order(yes.or no): Alarms in working order(yes or no) r Commnents(note condition of pump chamber,condition of pumps and appurtenances, etc.): s 8 Page.9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS, SUBSURFACE SEWAGE DISPOSAL SYSTEM,INSPECTION.N FORM PART C SYSTEM'INFORMATION.(continued) Property Address: 26 Hanson Lane Barnstable. MA - Owner: Wayne&Pat Dunham Date of Inspection: August 13, 2007 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: t ` o TYPe. leaching pits,number: 1 -6'x 6'(1000 gal.) - 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.): The.leach pit was dry and clean. There did not appear^to be any signs offailure. The bottom to grade was 8.5'. The cover was 30"below grade. CESSPOOLS: None (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 or no): :Comments (note condition of soil,signs of hydraulic failure,levelsof ponding; condition of vegetation,etc.):' PRIVY: None (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.): ,9 ' Page 10 of 11 OFFICIAL INSPECTION FORM-•NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 26Hans6n Lane Barnstable, MA Owner: Wayne&Pat Dunham' Date of Inspection: .- : Aukust 13, 2007 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.. a as aY 90 3 3,1 3 S 10 ' ,Page 11 of 11 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Address:. 26 Hanson Lane Barnstable, MA Owner: Wayne&Pat Dunham Date of Inspection: August 13, 2007 SITE EXAM Slope Surface water . Check cellar Shallow wells Estimated depth to ground water 60+/- feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain. topographic and water contours maps Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain' You must describe how you established the high ground water elevation: Using Barnstable topographic and water contours imps, the maps were showing approximately 60'+/-at this site. This report has been prepared only for the septic system and components described herein. This septic system has been inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will function properly in the future. There have been no warranties or guarantees, either expressed, written or implied,, relating to the septic systein, the inspection, this report and/or.any components of the septic system which have not been located and inspected. 11 • ' Town of Barnstable OF 1HE 1p� Regulatory Services BMxxsrnars Thomas F. Geiler, Director prED MA'S p 039. Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the"Disposal Work Construction Permit". If you should have any questions regarding this report,please contact the certified Septic System Inspector who conducted the inspection. LOCATION _ SEWAGE PERMIT NO. t L `fir_ ' 4,A) L A /V VILLAGE 13 I(cl_ I N S T A LLER'S NAME & ADDRESS f U I L 0 F N OR OWNER Ocelq A7 DATE PERMIT ISSUED �. �--^ � DATE COMPLIANCE ISSUED —/ — cf'/ I � , La�r' r THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH 31 G - . ...........OF.......RAPA(.C4,6 L.�--------------- Appliration for Disposal Works Tonstrurtiun Verutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ....._. ws�. ....: ------- __ -w l ...... ......... ... ----------------------------- --............------ ocation- ddress or Lot �'� Owe - Add es ------------------ ?D..�I ...1 � 1..............------...._....----•- --------------�r ..... �(/.�1 ............................... Insta ler Address Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms............a.............._..........Expansion Attic ( Garbage Grinder Other—T e of Building No, of persons____________________________ Showers — Cafeteria Other fixtures d -------------------.-•-----••----- W Design Flow...........5_S..........................gallons per person per day. Total daily flow.--._._..310.........................gallons. WSeptic Tank—Liquid capacity_tbsro_...gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width__.................... Total Length.....................Total leaching area....................sq. ft. 3 Seepage Pit No........Z.......... Diameter.....P........... Depth below inlet.... ........ Total leaching area_Z�.......sq. ft. Z Other Distribution box ( ) Dosing tank ( ) a Percolation Test Results Performed by.......................................................................... Date..................................... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------_................. G�+' •--•-------------------------•-••-....----------....------...._...•••-••------------.......•---.............................._........--•---...--•-...__----- oDescription of Soil....................................................................................................................................................................... x W ----••-•-•-•-------•.............•-•--•-•----------•-------•----------------------------....•---...---••------•---•------••---------••--•---••-----------------•---------------•-••----•------•-•_----- UNature of Repairs or Alterations—Answer when applicable............................................................................................... --------------------•-••--•------•----.......---•-----------------•-----------------•---............---•----....--------------------•---------------------------------------------..................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee ued by the board of health. Date 1/—/ " Application Approved By------ --•_� -- ------••••--•--•-•----- y-- g v Date Application Disapproved for the following reasons:-------•------------------------------------•----------•---•--------------------•-------------._........._•--- ...................•------...._...••----......-----------•••-----•--••---•-------•-......._..---•---...-------•-••---•-••-•-----.._..-----•---------------•----•---•--•-------•-----•-----•-•-•--------- Date PermitNo..........................................- l _ Date {R THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH -------....OF....... ,�, t. ✓ '. �*"`""'............. Appliratinn for Disposal Works Tonstrnrtiun jJrrmit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System5d ... ......... ........_....--------- t.. 1 �u .L. ----- .....z :�:. ..l�................................ It _n ddress f y� Lot / W " . . O Addres .J _ .:. .E1----------------------------•------ ............... Ir Address � Type of Building Size Lot...........................S q. feet Dwelling—No. of Bedrooms............. ...............Expansion Attic (A, ) Garbage Grinder OtherF—Type of Building =^'.............. No. ofpersons.-,--_-------- -------- Showers — Cafeteria Q' Other fixtures •_________________________________________________ .._E...... .._......_._....... ................ W Design;:Flow..... .,:r�: y�.......................gallons per person pee�day. Total daily flow.......3.10........ .......... WSeptic Tank—.,Liquid ca.pacity.lht.o...gallons Length................ Widtht_l..��....... Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------�---------- Diameter.....A....___.... Depth below inlet.... _........... Total leaching area.; -------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ Q+' .........................•--------•----•------------------------------------------------•----..............---•-----•-----•-•......... •--------•-------•--- -D Description of Soil..........................................................................................................................................•---•----------•------------- W U ........................................................................................................................................•-•------•................................................... UNature of Repairs or Alterations—Answer when applicable............................................................................................... ----•-----------------------------------•-•-----------------------•---•---•---------•.....----......--......-----------•----------•----------------•------•--•-••---•-----•--•......---------....••--•- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITTLE 5 of the State Sanitary Code—The undersigned`further agrees not to place the system in operation until a Certificate of Compliance has bee ued by th board of health. �r ate Application Approved By-•-•-. ---- A =at......�/-__ ........................................ . -•............... Date Application Disapproved for the following reasons:-------•--------------------------------------------------•-----------------•--•----------------------....•••••. ....................•------•-•--•..._..•--------------•----------•-......----------•-•---------•----------•-----------•-----------•-•-••-•----•-•---------------•-•--------•--•---------•-------...----- Date Permit No................ - .X`Issued.------ - .. F , Date- ... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT/H� d ........ 0... .........OF.......� 401 !ram 4 ............................. Trrtifiratr of Bunt li nrr THIS IS O0CERTIFY, Tha he Jndividual Sewage Disposal System constructed ( ) or Repaired ( ) by..^ = ..........................In-t r-•---- ----....-----•--•••-• -----------•-•-•••••---•----...-•-•----•--•---•••-•---••-- has been installed in accordance:with the provisions of:TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated----------...................................... THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FU CTION SATISFACTORY. f DATE..................... � / �" ........1...�'_...�.�.............•-------...._. Inspector........------ - THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...0 F...... .. . l................�t..� r No.. ��...`... % FEE... ' .... Di posy Works Tannstr ion rrmi# Permission is hereby granted.. -- •. ...---- to Construct (�or Repair ( ) an Individual Sewage Disposal System atNo------_------------ r�' °= _,r'x`� ? ....." ...-� ----------- -•---------.............................................. Street as shown on the application for Disposal Works Construction rmit No Dated ....................................... r � !� oZ:. �.. Board of,0 lealth DATE.......... FORM 12155 HOBBS & WARREN. INC.. PUBLISHERS % GAL. L-)Sp-- (c-,c—xn, C'AL . (-,C> 7c-> 6 0 5-1 Torl-A L .4ZIS &.Pr:>. 'T-c>-r.6 L AD Ak-I Lam 0 Ft-:-fZ-CDL&TI0Q t?-A.T-F= ["10 j-&ji 0' ofz I '74-8 7:2 A N,500 12— bet 1-7 '7 5 X-4,= qzZ L-,AAf 90,4 h;v 170 GAL. Xez> V,/i-rt.1 i Si t-F=C T I F-- Ez ID L V/ATErZ- e" '�:'ZTIP -r T1-�AT- TI-AU= 5"C?,Aj Q ko-j TZ 7=.T--G.z a Ij c a OT I DG jj,A C I,/- I Q G AA P TltC:7 PL TI-Al-IS V-?[-At-1 I-S t-JOT Ok-4 t-t-4 A p C- I,k:ir "I::. P C P-TEjz jo 9 SYSTEM PROFILE MARKED WITH SHALL BE C N ES o SYSTEM DESIGN: L COMPARABLE MEANS FOR FUTURE LOCATION. (NOT TO SCALE) APPROXIMATE NGVD O 1. DATUM IS a o 99 - EXISTING CONTOUR GARBAGE DISPOSER IS NOT ALLOWED ACCESS COVERS TO WITHIN 6" OF FIN. GRADE CONCRETE COVERS TO WITHIN 3' GRADE (SEE VENT NOT 0 PLAN Q X 99•1 EXIST. SPOT ELEV. TOP FOUND. EL. xx.x' 2' PEASTONE OR GEOTEXTILE 2. MUNICIPAL WATER IS EXISTING FILTER FABRIC OVER STONE R00Ie 6q DESIGN FLOW: 3 BEDROOMS ® 110 GPD = 330 GPD 91 0, 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT. 99 PROPOSED CONTOUR USE A 330 GPD DESIGN FLOW MINIMUM .75' OF COVER OVER PRECAST 2% SLOPE REQUIRED OVER SYST 91 .0' PRECAST H-10 BLOCKS OR -- 4. DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS �98.4� PROPOSED SPOT EL. RZS0ERs (TYP.) PRECAST RISERS - TO BE AASHO H-12 Q� TH1 SEPTIC TANK: 330 GPD (2) = 660 .a.. 4"SCH40 PVC 4"OSCH40 PVC H-20 TOP SYSTEM EL. 87.83' .9. ,.. PIPES LEVEL 1ST 2' MORTAR ALL a 5. PIPE JOINTS TO BE MADE WATERTIGHT. 5 �� +~ 4' COMPONENTS INV'S EL. 86.83' 4 ** TEST HOLE RE-USE EXISTING 1000 GAL. SEPTIC TANK !' "EXISTING 1000 GAL ENDS (TYP.) SIDES � o *EXISTING555555555o 06. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH Qr s oc s 10" SEPTIC TANK 14" no o ro vo v° o 0 0 0 2> SLOPE OF GROUND o 0 0 >°o°o°o°o ( ) B! LEACHING: EXISTING TEE TEE \*87.51 ®®®® ®®�® ®��(] -®®®® 310 CMR 15.000 TITLE V. a9g > o ° ° ° >°o°o°o°o Q UTILITY POLE SIDES: 2 (25 + 12.83) 2 (.74) = 112 GPD °°°°W86.8 o ®® ;00000000° ° °o°o°o°o Eqmmr7m 2mmm ®®®®®®®®®®® 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TOGAS BAFFLE .; ooQo Cj ,00000000 0 0 0° ° ®® ®® °°°° BE USED FOR LOT LINE STAKING OR ANY OTHERFIRE HYDRANTBOTTOM 25 x 12.83 (.74) = 237 GPD 87.06' 9' °°°°°°°° ° ° ° ° PURPOSE. ,00000000 O :' n NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING , TOTAL: 472 S.F. 349 GPD - EL. 84.83' 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. �O/fe 6 3/4"-1-1/2" DOUBLE WASHED STONE 4' MIN. H 20 500 GAL. LEACHING CHAMBER BY ACME PRECAST OR EQUAL. DEPTH OF FLOW - 4 (2) UNITS REQUIRED 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED USE 2 500 GAL. LEACHING CHAMBERS ACME OR EQUAL ALL AROUND PRECAST STRUCTURES WITHOUT INSPECTION BY BOARD OF HEALTH AND ( ) ( ) TEE SIZES: of 6" CRUSHED STONE OR MECHANICAL OVERALL DIMENSIONS TO OUTSIDE OF STONE: 25.00' X 12.83' PERMISSION OBTAINED FROM BOARD OF HEALTH. WITH 4' STONE ALL AROUND INLET DEPTH = 10- COMPACTION. (15.221 [2]) 00 *THE INSTALLER SHALL VERIFY THE LOCATIONS OF ALL UTILITIES AND ALL OUTLET DEPTH = 14„ "'' 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING BUILDING SEWER OUTLETS AND DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES ELEVATIONS PRIOR TO INSTALLING ANY LOCUS MAP 79.0' BOTTOM TH-1 PRIOR TO COMMENCEMENT OF WORK. PORTION OF SEPTIC SYSTEM ( 1 y. SLOPE) ( 1 % SLOPE) NO GROUNDWATER FOUND 11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE SCALE 1"=2000'f MA REMOVED 5' BENEATH AND AROUND THE PROPOSED APPROVED DATE BOARD OF HEALTH FOUNDATION EXISTING SEPTIC TANK 44 D' BOX 8' LEACHING LEACHING FACILITY. FACILITY ASSESSORS MAP 316 PARCEL 92 12. EXISTING LEACHING FACILITY SHALL BE PUMPED AND REMOVED OR PUMPED AND FILLED WITH CLEAN SAND. LOCUS IS WITHIN AP OVERLAY DISTRICT **THE INSTALLER SHALL CONFIRM MIN. SEPTIC TANK SIZE AT 1000 GALLONS AND ITS SUITABILITY FOR RE-USE 5' REMOVAL OF UNSUITABLE SOIL REQUIRED AROUND PERIMETER OF LEACHING FACILITY, DOWN TO SUITABLE SOIL LAYER. REPLACE WITH CLEAN MED. SAND. ENGINEER TO INSPECT AND CERTIFY PROVIDE VENT WITH CHARCOAL FILTER REMOVAL. 216.53' AND BUGSCREEN (FINAL PLACEMENT WITH HOMEOWNER CONSULTATION) g 93 92 TEST HOLE LOGS 94 00 ENGINEER: DAVID FLAHERTY, R.S., SE2755 LOT 106 �� 00 WITNESS: DONNA MIORANDI, R.S. 43,657f SF o DATE: OCTOBER 20, 2008 � PERC. RATE _ < 2 MIN I k4 93 SWALE \�\ � 5. CLASS I SOILS P# 1 C N t v 0� ELEV. _.-E EV. 92 TH 2 0„ �% 91 .0' 0„ ..._._ 91 .0' BENCH MARK - THRESHOLD O A A AT BASEMENT SLAB EL. = 89.1 :t. ` LS LS o� T sp 4„ 1OYR 3/2 6 1OYR 3/2 92 _ B B 92 / LS LS w 93 / 1OYR 5/6 1OYR 5/6 io c3` 22 89.2 34 88.2' 9,3 9� K - o / C1 C1 0 w �� SILT LOAM SILT LOAM 90" 2.5Y 6/4 83.5 2.5Y 6/4 , 1 96 83.0 ) I _i O Q2 C2 SIEVE o EXISTING 3 BR DWELLING TOP OF FNDN I owl , MS MS EL. 96.2' z / CTV_CTV O 144" 2.5Y 7/3 79.0' 144" 2.5Y 7/3 79.0' CTV-CTV-CTV \� I v NO GROUNDWATER ENCOUNTERED � tD TITLE 5 SITE PLAN PAVED o\ OF (( DRIVE I o 26 HANSON LANE 1 � 1 i BARNSTABLE, MA PREPARED FOR ANDREW PRCHLIK j DATE: OCTOBER 21 , 2008 ' Scale: 1"= 20' A, R; L 007 Lane 0 10 20 30 40 50 FEET Hans�n CFMgSsf/� �INOFMASsgC off 508-362-4541 DANIELA. �Gs �° DANIEL y�N fax 508-362-9880 + U� OJALA ``+ J A. N I downcope.com © �f CIVIL ! �No.46502v �0 0.40980 down cape engineering, /dc. Fss! "a S R��y°4 civil engineers ONAL ti �_, - land surveyors 939 Main Street ( Rte 6A) DATE DANIEL A. OJALA, P.E., P.L.S. YARMOUTHPORT MA 02675 BICE #08-253 08-253 PRCHLIK.DWG (DDF)