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HomeMy WebLinkAbout0049 INDIAN HILL ROAD - Health 749 Indf,an HiII,Road w.. Bamstable P,, J a • •` 3310 �� assachusetts Commonwealth of M �. Title 5 Official Inspection Form ��• Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 4= 49 Indian Hill Road ' Property Address ? Lee Hill fit:? Owner Owner's Name ' information is required for every CummaquidN, Ma 02636 6-5-2019 -` 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 (Shot_ 139Scl 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 key. Company Name 374 Route 130 Company Address VQ Sandwich Ma 02563 City/Town State Zip Code (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. ❑3 Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails Brett Hickey �°�"°-°°e-""�" 6-5-19 •--.ON:m=BnR NiGey,o,ou,emeA=aRim®�an00ovava0on nal,oU5 ''—tlzte:201 B.08.0]1°:]1:55 04'W 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 4 �n Title 5 Official Inspection Form + ii Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Indian Hill Road V Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 ,> R 6-5-2019 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): I t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts �d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Indian Hill Road Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 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): ❑ 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 ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ 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/M8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 y c Commonwealth of Massachusetts v ,lp Title 5 official Inspection Form ~ 1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Indian Hill Road Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 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 passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 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 Backup of sewage into facility or system component due to overloaded or ❑ clogged SAS or cesspool ❑ El 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts �n Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Indian Hill Road V Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 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 ❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ a. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ 0 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. ❑ Q Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ 0 The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 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 ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply h ❑ ❑ 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 cam, Commonwealth of Massachusetts ,lp Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Indian Hill Road Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 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 ❑ El 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? ❑ 0 Have large volumes of water been introduced to the system recently or as part of this inspection? El ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ❑ 0 Was the facility or dwelling inspected for signs of sewage back up? 0 ❑ 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? ❑ ❑ 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: El ❑ Existing information. For example, a plan at the Board of Health. ❑ Q 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 Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments v- 49 Indian Hill Road Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: 4 Number of bedrooms(design): Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440/GPD Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes El No Does residence have a water treatment unit? ❑ Yes [0 No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes Q No See below Water meter readings, if available(last 2 years usage(gpd)): Detail: ***2017- 111,000gallons 2018- 70,000gaIIons*** Sump pump? CU Yes ❑ No Current Last date of occupancy: Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 c Commonwealth of Massachusetts v Title 5 Official Inspection Form1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Indian Hill Road Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 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: Owner- date of last pump is unknown Source of information: Was system pumped as part of the inspection? ❑ Yes 0 No If yes, volume pumped: gallons h How was quantity pumped determined? Reason for pumping: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 cam, Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Indian Hill Road Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: El 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 tank added to existing SAS in 2015. SAS installed 2003 Were sewage odors detected when arriving at the site? ❑ Yes 0 No 5. Building Sewer(locate on site plan): 1'6" Depth below grade: feet Material of construction: ❑ cast iron 0 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.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 I� Commonwealth of Massachusetts V �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Indian Hill Road ,v Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 6" Depth below grade: feet Material of construction: U concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1500gallons H2O 4" Sludge depth: 3211 Distance from top of sludge to bottom of outlet tee or baffle 211 Scum thickness 611 Distance from top of scum to top of outlet tee or baffle 15" 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 in need of pumping at this time and 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 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Indian Hill Road Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): NA Depth below grader 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: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 cf Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments `............. 49 Indian Hill Road Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 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. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Indian Hill Road Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 required for every 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: (3)500 gallon chambers 0 leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ 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 J c Commonwealth of Massachusetts �. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Indian Hill Road u� Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 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. No evidence of past back up was observed. 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.7/26/2018 Tide 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 49 Indian Hill Road u— Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): NA Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.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 l; 49 Indian Hill Road Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 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 Cti�ixl.tlYW v:7�A'�f1 PHif)i�7a via C1�tfc C fa r C C+¢ �S ......w.._.SX ,AST T , T#rlf}37�.ct F f YI:i I Y.'f;tyi=1 (size') r ca.s r :t stYr c�nIS c... ; :.Si ttrar i�si tYifi:aijCe aerw*n tue, - M:ein�uxn-,4dja�.sied Cirtac�ii watrr Tidble iSo tha.'t3ixtinm,al�T:;raching,t?ariltt� ...__.__.._�_ Feet f?a-t's a2e;: Yrr�iuti�h lVei3 zinc.Leal Ei�ra$Fsc.tity".(T,fany wells exim xrii: - sitcorwxYhirt'.tt7t>fecY:e�ticartu.igYacilay,:. Feet. _ 3=.dge uk'LLei::.�J;ytix3.I;rsri:uaa .Faaili4y i`kf tu-i.°`u>i„Ylands cxvt'widaux: - ,fisrx�f•lk�a�txn'��Y:��kh^vt'.. . f',r.�t 2. el. Al i l5insp.doc-rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts �m Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Indian Hill Road Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.). 15. Site Exam: Check Slope Surface water ❑13 Check cellar 0 Shallow wells No GW @ 180" Estimated depth to high ground water:* feet Please indicate all methods used to determine the high ground water elevation: El Obtained from system design plans on record If checked, date of design plan reviewed: 3-31-03Date ❑ 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. 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 I_ cf Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 49 Indian Hill Road U Property Address Lee Hill Owner Owner's Name information is Cummaquid Ma 02636 6-5-2019 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: On A. Inspector Information: Complete all fields in this section. ❑l3 B. Certification: Signed & Dated and 1, 2, 3, or 4 checked 0 C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist)completed 0 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 l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Page 1 of 1 TOW?OF BARNSTABLE LOCAT7(3N A: INSTAI LR'S NAME&PHONE.N(3 Crh �a u.� ?,n SEPTIC TAN CAPACITY.. .. - --��_ ;77� a, a� LEACI" NG FACE ITY'(iypej' NO.OF BEDROO-MS I PERMIT DATE; . . . CUMPI IANCE DATE: Separation Distance Between the:, MaxinitimAdjwted t roundwatez Table to the Bottom of Leaching Facility Feei P.riyate Water Supply Well and Leaching Facility.(If Fywells exist on. site, feet of leaching.fac�lity) Feet Edge of Weiland and Leaching Facility{If any wetlands exist.within 566 feet of leaching facility} Feet h[TR1vISl3I'D-BY d IT QQ' 5/24/2019 TOWN O�; F��BARNSTABLE LOCATION yq -16 `sg r\ \�°\\ `� SEWAGE# VILLAGE 2bMS�a\Q\e- ASSESSOR'S MAP&PARCEL33 INSTALLER'S NAME&PHONE'NO. gQQp, Qo6 SE�C Sec\P Mc- �nG SEPTIC TANK Iff CITY Pdt u L "a�-t, 7 LEACHING FACILITY.(type) (size) NO.OF BEDROOMS � n OWNER PERMIT DATE: 13// COMPLIANCE DATE: g3 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 oj--,-r eA C A 2 �o�� � a ��� y. �� No. 43 / J Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2ppliLation for BispoBal 6pstem ConstrULtlon permit Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address,and Tel.No. L e t_- Assessor's Map/Parcel l„ �3(D DQ 5 6 Installer's Name,Address,and Tel No ��'' �s �� Designer's Name,Address,and Tel.No. 33 ac' u. �y Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow,(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date _ Title Size of Septic Tank Type of S.A.S. Description of Soil f Nature of Repairs or Alterations(Answer when applicable) L ,lo�/J /„f'0e, 4l/9 Date last inspected: Agreement: r 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 Health. ed Date 3 Application Approved by i Date .3 l Application Disapproved by Date for the following reasons Permit No. Date Issued g 3 J-5 No 'Felod e ` THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: C. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 2pplication for bisposar 6pstern Construction permit Application for a Permit to Construct( ) Repair Upgrade(. ) Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. L,l� 9/ies7 // /c00" Owner's Name;Address,and Tel.No. 4 e Assessor's Map/Parcel9 Installer's N e,Address,and Tel No. >>s`-.�8pr Designer's Name,Address,and Tel.No. 3J o r Type of Building: Dwelling No.of Bedrooms + Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd F_ Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: 4r 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 I Compliance has been issued by this Board of Health. A, j t Date Application Approved by Date 3�� Application Disapproved by Date t for the following reasons PermitNo. �j 5� Date Issued--------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certif cate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( ) Abandoned( )by /��/ /ii�i e!7:<i at 9 _Z'� i�, �!,�/ �r/. has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.,__)O)5 9.5 Ited Installer ����� �j� Designer #bedrooms Approved design flow , gpd The issuance of this permit shall not bef construed as a guarantee that the system�Will function ash designed. Date ( � J - Inspector --------------------------------------- No. a Fee /0 Vll THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Misposal *pstem Construction Permit Permission is hereby granted to Construct( ) Repair(v< Upgrade( ) Abandon( ) System located at e?/5f ,;2 a" 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:Construction must b comple ed within three years of the date of this pe it. Date ,� Approved by I� i u3t SEF i ROAD' � USE 39.9 6 p _ 40 LEE DIAN4 .9 s: BENCH MARK TOP OF BARNSTABLE ROAD BOUND + .4 EL. = 42.0 (ASSMD) ' X I LOT A EA TO' 26"' 0 ` b5 W + 4 I 123,475± Q. FT. �4 1 US -�-"4 12" CEDA 20" CEDAR I OR 54t A RES 25.60 41.1 A - o ® AREA 4. PLANTI GS 4 S 15T. 44 I I N Q �lUoY" + 4 4 44.6x` r+ 3.3 + 40.1 .' yt d e I 4.4 41.1 4 k 1 Fy n 0 3 I CHO LY N EXIST. DWELL. T 4 4 45.0 '4 +�2.7 O ` 0.2 a 1l3" CEDAR + 3.2 O + 43.8 41.9 40.3. i 7 CEDAR / C)�. +.41.1 6" HOLL A 14 E A � ? I� 40.7_,�, 38.1 �. 200.00' 4 + 40.5 AF + 40.8 + 40.3 5' REMOVAL OF UNSUITABLE SOIL REQUIRED AROUND PERIMETER OF LEACHING FACILITY, DOWN TO SUITABLE D O LE SOIL LAYER 8 (APPROXIMATELY 1 WN . REPLACE WITH 1 DO CLEAN MED. SAND. ENGINEER TO INSPECT AND CERTIFY REMOVAL 62 4 BR SAS ,a COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 491ndian Hill Road 00-5 Cummaguid, MA 02637 Owner's Name: Jean Hill. Owner's Address: P.O. Box 330 Cummaquid, MA 02637 Date of Inspection: May 12, 2006 Name of Inspector: (Please Print) Janses M, Ford .w Company Name: James M.Ford Mailing Address: P.O.Box 49 ' Osteryft MA 02655-0049 ° Telephone Number: (508)862-9400 ;t , 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 lam a DEP rat approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ✓ Passes Conditionally Passes Nee s Further Evaluation by the Local Approving Authority Fail Inspector's Signature: Date: May 18, 2006 The system inspector shall sub it 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. 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued), Property Address: 491ndian Hill Road Cummaguid MA Owner: Jean Hill Date of Inspection: May 12, 2006 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: r B. System Conditionally Passes: One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for t1le 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. 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): a 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'pip e(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: 49 Indian Hill Road Cummaguid, MA Owner: Jean Hill Date of Inspection: May 12, 2006 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 F 2. System will fail unless the Board of Health,(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system(SAS)and the SAS is within'100 feet of a surface water supply or tributary to a_surface water supply. The system has a septic tank"and SAS and the SAS is within'a Zone 1 of a public water supply. The system has a septic tank`and SAS and the SAS is within 50 feet of a private water supplyyell. The system has a septic tank and SAS and the.SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria 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 ppni,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: ; 3 f Page 4 of 11 , OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM PART A z CERTIFICATION (continued) Property Address: 49-Indian Hill Road Cummaauid, AM Owner: Jean Hill Date of Inspection: May 12, 2006 D. System Failure Criteria applicable to all systems: A 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 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'h 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. ✓ 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 frowthat 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 that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should"contact the Board of Health to determine what will be necessary to correct the failure. E. Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 god to 15,000 god. You must indicate either"yes"or"no"to each of the,following: ` (The following criteria apply 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 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. 4 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 491ndian Hill Road Cummaauid MA Owner: Jean Hill Date of Inspection: Ma 12, 2006 r 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 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: 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)]. f 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 49 Indian Hill Road Cummaauid, MA Owner: Jean Hill Date of Inspection: M 12 2 p 006 May 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: 2 Does residence have a garbage grinder(yes or no): Yes Is laundry on a separate sewage system(yes or no): n1a [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 1 1 , 1 -. Last date of occupancy: Currently occupied COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd 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): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: New system-never pumped(per owner). 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 information: Installed on 5119103-per as built card Were sewage odors detected when arriving at the site(yes or no): No 6 f Page 7 of I I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) .' Property Address: 49 Indian Hill Road Cummaquid, MA Owner: Jean Hill Date of Inspection: ME 12, 2006 BUILDING SEWER(locate on site plan) Depth below grade: None ' Materials of construction: _cast iron 40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on site plan) . . Depth below grade: 4" Material of construction: ✓ concrete _metal _fiberglass _polyethylene . _other(explain) ; If tank is metal list age: Is age confirmed by 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 baffle: 6" , Y Distance from bottom of scum to bottom of outlet tee or baffle: 10" ' How were dimensions determined: Measuring stick Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity; liquid levels as related to outlet invert,evidence of leakage,etc.). Tees were present. The liquid level was even with the outlet invert There did not appear to be any signs of leakage GREASE TRAP: None (locate on site plan) m Depth below grade: 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: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49Indian Hill Road Cummaduid, MA Owner: Jean Hill Date of Inspection: Mav 12. 2006' F. TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on siteTplan) t Depth below grade: : Material of construction: ._concrete _metal _fiberglass `'_polyethylene _other(explain): - a Dimensions: Capacity: gallons .' _ • 4 .. Design Flow: gallons/day Alarm present(yes or no): r Alarm level: Alarm in working order(yes or no). _ e Date of last pumping: Comments(condition of alarm and float switches,etc.): p "e 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.): F The D-box was even. 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) Comments(note condition of pump chamber,condition of pumps and appurtenances;etc.): .t A Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 Indian Hill Road Cummaauid. MA Owner: Jean Hill Date of Inspection: May 12, 2006 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: ✓ leaching chambers,number: 3-500 Qal. leach chambers with 4'stone(per desirznplans) 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.): A video camera was used for the inspection There did not appear to be ciny signs of failure 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,level of 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 t t. Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: . 491ndian Hill.Road Cummaguid, MA Owner: Jean Hill Date of Inspection: May 12, 2006 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. # , y 3 a a1 36 yl ys() 41-7 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continuedj 4 Property Address: 49 Indian Hill Road Cummaquid, MA r Owner: Jean Hill " Date of Inspection: May 12, 2006 SITE EXAM Slope Surface water Check cellar ' Shallow wells Estimated depth to ground water 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: .5115102 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: ' According to the design plans on file, water was located 5'below the bottom of the leach chambers 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 system, the inspection, this report and/or any components of the septic system which have not been located and inspected. 11 ' tel.(508)362-4541 939 main street rt 6a fax(508),362-9880 yarmouth port mass 02675 down 'cape engineering civil engineers& land surveyors structural design Arne H.Ojala P.E., P.L.S. Daniel A.Ojala, P.L.S. . land court a Timothy H.Covell,P.L.S. surveys . May 22, 2003, site planning Thomas McKean, RS sewage system Director, Barnstable Health Department designs 200 Main Street Hyannis, MA 02601 inspections Re: 49 Indian Hill Road, Cummaquid permits Dear Tom: On May 15, 2003, Down Cape Engineering, Inc. performed a soils removal inspection as required on the approved plan at the above-referenced location. This is to certify that the soils removal was completed satisfactorily. If you have any questions, please do not hesitate to call me,, ours truly f \. �.rne H. Ojala, PE, PLS Down Cape Engineering, Inc. cc: L. Hill f - TOWN OF BARNST,ABLE LOCATION , c .SEWAGE # VILLAGE ►vlif. ASSESSOR'S MAP.&LOT3(o-60 INSTALLER'S.NAME&PHONE NO.. SEPTIC TANK CAPACITY � G'•9uQ^.'�S ,� LEACHING FACILITY: (type) �,��Ul/��5 �J (size) __! :k2 NO. OF BEDROOMS BUILDER OR OWNE PERMITDATE:' COMPLIANCE DATE: 9 LO 3 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 aching facility) Feet Furnished by 20 r. 3 /N y x r l C TOWN F BIARNS;TABLE 9 L(k r l TUN L 1 t Sf, GE # VILLAGE mum M CO W ASSESSOR'S & LO _�� INSTALLER'S NAME&PHONE NO. L OTS SEPTIC TANK CAPACITY 160, 6 ��� LEACHING FACILITY: (type � C� f�(size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and 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 A TOWYOF BARNST LE .OtATION b SEWAGE # _.VILLAGE rY1R WNA ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) :: '2 NO. OF BEDROOMS .BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: 9 3 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 aching facility) Feet Furnished by CA C� a TOWN/ /IOF BA�RNSTABLE C OCATION ` 1 Lt�14�1 `'�i l/ �C• SEWAGE# 03/37 VIL-CAGE ASS OR'S MAP&PARCEL 336— ODS-' SEPTIC TANK CAPACITY LEACHING FACILITY:(type) 3- 560 Ar/cozl_l (size) NO.OF BEDROOMS 3 OWNER m�l 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/1.�OecTllh 'T �D�C 1D 0 a i a ai 30 3 y 3 y1 q/ �... . y 90 417 No. �' (37 + Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for r3igool *p5tem Construction Permit Application for a Permit to Construct(x)Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. (5-4 r.) ,363-6Q6� 69 QAJSTA QCk-c- /-CC N,,k L Assessor's Map/Parcel _��. G ox 33o� Cu,.tnt�4jv rJ //�� oa4 3 f i Installer's Name,Address,and Tel.No. C 60'V .�TS' 5993 Designer's Name,Address and Tel.No. Cho r) 3�y IrIS�/ PKrn a,07mc-roo-s -,rA)e-. --PO0�+ CtO4 P6- 689*/,s EE�i Type of Building: Dwelling No.of Bedrooms_ Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) Date last inspected: Agreement: The undersigned agrees to ensure the construction and mamtenan e of the afore described on-site sewage disposal system in accordance with the provision it he Environmental Coe nd not to place the system in operation until a Certifi- cate of Compliance has been issue W y/ / Signed Date / Application Approved by Date ©3 Application Disapproved for the following reasons Permit No. i`3`7 Date Issued �� t No. � Fee_., THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: `i PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes Application for Ofi5pont *pztem Construction Vermit { Application for a Permit to Construct(x)Repair( ),Upgrade( )Abandon( ) ❑Complete System ❑Individual Components - ,Location Address or Lot No. Owner's Name,Address and Tel.No. `s o�� ;76�— Q1_)S"t A 8-C.E- IS o y 0, U Assessor's Map/PMap/Parcel 3 3 (_� M M A�v � ,i a JMA a � 7 Installer's Name,Address,and Tel.No. 15 0� 3`dS- S 9� Designer's:Name,Address and Tel.No. i�5o O -r � c,,d,J P c�,J /,v •Pr 4/r 939 /%9i� s7r �Jt9�PrnUvT�/�o 0 6 Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ` Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank, Type of S.A.S. I Description of Soil �s Nature of Repairs or Alterations s(Iknsweriwvhen applicable) =�- 4 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 tt er of1he Environmental Co and not to place the system in operation until a Certifi- cate of Compliance has been issued b d of K. / Signed /J ' ..< Date ' Application Approved by, t Date Z/A//©3 Application Disapproved forth' following reasons 4 Permit No; 2-00 3--1317 Date Issued THE COMMONWEALTH OF MASSACHUSETTS f BARNSTABLE, MASSACHUSETTS ce # ""Zertif icate of Compliance ,-,,,THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(n)Repaired( )Upgraded( ) Abandoned( )by K/1'1 rSICT`�a�S a at V 4 :Z�kf IA,) k/l )l bQd, has been constructe in ccordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2003-/3 7 dated Al5/ 03 Installer AK44 n42:LWAtn•704S. _:7 l C- Designer`J)o ,o (? DE The issuance of this pe ;t sha knot be construed as a guarantee that the syste t o s <est ned. i Date 0 3 Inspector No. 2 ? 1'?_ (3f7Fee c/ THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS 1=i6pogal *pgtem Contructton permit Permission is hereby granted to Construct( /7 Repair( )Upgrade( )Abandon( ) System located at 112 9!�_ _, and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Cons�ruc on must be completed within three years of the date of this permit. Date: q `/j 0 3 Approved by 1 f 1. 3 .H. . - COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Grad DEPARTMENT OF ENVIRONMENTAL PROTECTION_ DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 z TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART A CERTIFICATION Property Address: 49 INDIAN HILL RD. CUMMAQUID �j� LU— Name of Owner JANICE BENDER Address of Owner: BOX 382 CUMMAQUID MA.02637 4 Date of Inspection: 11/19/99 Name of Inspector:(Please Print)JOHN GRACI 1 am a DEP approved system inspector pursuant to Section 15.340 of TIBe 5(310 CMR 15,000) DEC 16 `® Company Name: n/a 61999 & Mailing Address: n/a Telephone Number: n/a 4 CERTIFICATION STATEMENT L 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 inspection.The Inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.The system: e X Passes The Inpectlon is based on criteria defined in Title V Conditionally Passes ,code 310 CMR 15.303.My flndings are of how the system Is Needs Further Eval It n By the Local Approving Authority performing at the time of the Inspection.My Inspection does Fails not imply any warranty or guarantee of the longgevity of the septic system and any of Its components useful life. k Inspector's Signature: Date:11/19/99 ' The System Inspector shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS t THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING THE SYSTEM EVERY TWO YEARS TO PROLONG THE SYSTEMS USEFULL LIFE.RECOMMEND RAISING AND REPLACING THE COVER TO THE LEACH PIT." revised 9/2/98 Page 1 of 11 ` s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) .Property Address: 49 INDIAN HILL RD.CUMMAQUID' Owner: JANICE BENDER Date of Inspection:11/19/99 `+ , INSPECTION SUMMARY: Check A, B, C, or Dr ." t A. SYSTEM PASSES: t, _ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. a _ COMMENTS: M System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: ELS 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or extiftration,or tank failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as approved by the'Board of Health. nta Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box.The system will pass Inspection if(with approval of the Board of Health). broken pipe(s)are replaced obstruction is removed _ distribution box is levelled or replaced nLa The system required pumping more than four 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 u f revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM$ ua PART A CERTIFICATION(continued) Property Address: 49 INDIAN HILL RD.CUMMAQUID _ Owner: JANICE BENDER Date of Inspection:11/19/99 a 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 the public health,safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of surface water , Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS Is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well, The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis 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,Method used to determine distance nLa_(approximation not valid). 3) OTHER �>z nta revised 9/2198 Page 3 of 11 =.. 4 SUBSURFACE SEWA_GE�DISPOSAL SYSTEM INSPECTION FORM c PART A ` CERTIFICATION continued r v.t a Property Address: 49 INDIAN HILL RD.CUMMAQUID t ,•k r 4., ' Owner: JANICE BENDER 3 m Date of Inspection:11/19/99 D. SYSTEM FAILS: rx " x z A You must indicate either"Yes"or"No"to each of the following.. I have determined that one or more of the following failure conditions wftt'as described in 310 CMR 15.303:The basis for this determination is identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure:' Yes No s +$ gy X Backup of sewage into facility or system component'due to'an overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.~ , X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS'orcesspool, X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT,due to clogged or obstructed pipe(s) Number of times pumped n&. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. s 3 r X Any portion of a cesspool or privy 1s withiri 100 feet of a surface water supply or tributary to aL surface water supply. r � X Any portion of a cesspool or privy is within a Zone i of a public well X Any portion of a cesspool or privy Is within 50 feet of a'private water supply well,p. X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supplywell with'no acceptable water quality analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,'volatile organic ompounds, ammonia nitrogen and nitrate nitrogen. . . - X The liquid level in the SAS is over the invert pipe is in Hydraulic Failure' E. LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following, The following criteria apply to large systems in addition to the criteria above �.' x.. - .r.• . e _ The system serves a facility with a design flow of 1l),006 god or greater(Large System)and the system is a�significant threat to public health and safety and the environment because one or more.of the following conditions exist: ". t • , ' Yes No X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary,to:a surface drinking water supply X 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) Ij The owner or operator of anysuch system shall upgrade the system in accordance with 310 CMR 15.30414 Please consult the local regional office of the Department for further information .h ;s' r � rE `;" e `' •r Na revised 9/2/98 �- 's F :_ Page 4 of 11 r .. '1-a s' �:,` M cY E Y�:M, •` L. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B aj CHECKLIST Property Address: 49 INDIAN HILL RD.CUMMAQUID" ' Owner: JANICE BENDER ' Date of Inspection:11/19/99 " Check if the following have been done:You must Indicate either"Yes"or"No"as to each of the following: Yes No " X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped forrat least two weeks and-the system has been receMng normal flow rates during that period.Large volumes of water have not been Introduced into the system recently or as part of this inspection. G X As built plans have been obtained and examined.Note If they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up X The system does not receive non-sanitary or Industrial waste flow. • - y X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge,depth of scum.'The size and location of the Soil Absorption System on the site has been determined based on: . X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) [1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provide_d with information on the proper maintenance of SubSurface Disposal Systems. L - • .. r• 'M a tV .i '!'Y4 ^ r� � • r £' • of revised 9/2198 {Page 5 of 11 , L SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s ' PART A" n SYSTEM.INFORMATION' :'' Property Address: 49 INDIAN HILL RD.CUMMAQUID `' t s # ' P g Owner: JANICE BENDER ,a Date of Inspection:11/19/99 t - ti .• .-. ' r' .r "° FLOW CONDITIONS x . R RESIDENTIAL: - Design flow: =g.p.d./bedroom Number of bedrooms(design)'. 2 Number,of bedrooms(actual) 2 : �� r Total DESIGN flow: Number of current residents:) Garbage grinder(yes or no):N_Q w P . ' r °� 44 Y Laundry(separate system)(yes or no): INO If yes rseparate Inspection required a Laundry system inspected(yes or no):M " Ir Seasonal use(yes or no):AQ Water meter readings,if available(last two year's usage(god): n&a 4 Sump Pump(yes or no): Na 4 a •� „ Last date of occupancy: nLd r k y COMMERCIALIINDUSTRIAL Type of establishment: nLd j; Design flow: nla grd(Based on 15.203) 4 �., • . Basis of design flow: nLa4,- ek z<� Grease trap present:(yes or no):JLQ Industrial Waste Holding Tank present:(yes or no): XG Non-sanitary waste discharged to the Title 5 system (yes or no):I Q Water meter readings.if available:nLa Last date of occupancy: n1a uv OTHER: (Describe) nLa * a d 5, Z. - d � •Y. . - Last date of occupancy: nta °s .d d GENERAL INFORMATION , " '' ' PUMPING RECORDS and source of information:. SYSTEM WAS LAST PUMPED 5 YEARS AGO BY CANCO System pumped as part of inspection:(yes or no) If yes,volume pumped nLa_ gallons Reason for pumping: n s u p �0 La TYPE OF SYSTEM XSeptic tank/distribution box/soil absorption system Single cesspool ik f ,¢ '• Overflow cesspool : •r! ° x" p # v P Privy Shared system(yes or no)(if yes.attach previous inspection records,if any) I/A Technology etc.Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other: nta fl '* T, A e-, , APPROXIMATE AGE of all components,date installed(it`known)and source of information - � �xrF �•�� a THE SYSTEM IS APPROXIMATELY 30 YEARS Sewage odors detected when arriving at the site (yes or no) tY4 - •� � 0 . - s ,. ' a � gc sari. a t J* r* revised 9/2/98 W, Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I PART C SYSTEM INFORMATION(continued) Property Address: 49 INDIAN HILL RD.CUMMAQUID »'s Owner: JANICE BENDER Date of Inspection:11119/99 BUILDING SEWER: (Locate on site plan) w Depth below grade: 1 Material of construction:_ cast iron X 40 PVC _ other(explain) e Distance from private water supply well or suction line: TOWN ' Diameter: nta Comments: (condition of joints,venting,evidence of leakage,etc.) r Wa SEPTIC TANK: X (locate on site plan) Depth below grade: Material of construction:X concrete_ metal_ Fiberglass!_ Polyethylene _ other(explain) nta If tank is metal,list age Is age confirmed by Certificate of Compliance(Ye*No): No nla Dimensions: L 8_6"H 5'7"W 4'9" Sludge depth: Z ' Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: y P " Distance from bottom of scum to bottom of outlet tee or baffle: IZ= How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING EVERY TWO YEARS GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal'_ Fiberglass _ Polyethylene_other(explain) Wit Dimensions: nLa s ,, Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle Wa _Date of last pumping: n& Comments: . (recommendation for pumping,condition of Inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) Wit revised 9/2198 -. Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 INDIAN HILL RD.CUMMAQUID Owner: JANICE BENDER Date of Inspection:11/19/99 A " TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) a Depth below grade: nLa ' Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain), nLa Dimensions: nta ' Capacity: nLa gallons « 5. Design flow: nta gallons/day Alarm present: NO Alarm level:jiLa- Alarm in working order:Yes_No MQ Date of previous pumping: nLa Comments: ,. (condition of inlet tee,condition of alarm and float switches,,etc.) n1a DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:nLa " Comments: , (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)f i nia PUMP CHAMBER: hQ (locate on site plan) Pumps in working order:(Yes or No): No Alarms in working order(Yes or No): MQ t Comments: - (note condition of pump chamber,condition of pumps and appurtenances.etc.) µ, nLa t revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ° PART C SYSTEM INFORMATION(continued) Property Address: 49 INDIAN HILL RD.CUMMAQUID F. Y Owner: JANICE BENDER Date of Inspection:11/19199 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain:nta n - - Type: leaching pits,number: > leaching chambers,number: leaching galleries,number: .n/a leaching trenches,number,length: nLd leaching fields,number,dimensions: nLd overflow cesspool,number: 6'X6'BLOCK CESSPOOL Alternative system: nLd Name of Technology: j]L;i Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE BLOCK CESSPOOL IS STRUCTURALLY SOUND AND FUNCTION PROPERLY THE PIT HAD 2'OF WATER IN IT CESSPOOLS: (locate on site plan) ti Number and configuration: nLa - Depth-top of liquid to inlet invert: nld Depth of solids layer: Wa r Depth of scum layer. nta Dimensions of cesspool: Wa Materials of construction: n!A ` Indication of groundwater: nLa inflow(cesspool must be pumped as part of inspection)n!H a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nLa PRIVY: _ (locate on site plan) { Materials of construction:nLa Dimensions:n!A Depth of solids: nLa Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) nla revised 9/2/98 Page 9 of 11 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM " PART C _ , SYSTEM INFORMATION(continued) Property Address: 49 INDIAN HILL RD.CUMMAQUID - Owner: JANICE BENDER Date of Inspection:11/19/99 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes Into house) '• n/a i � 31 ,. _ a ,,.� r a - '• s ., revised 9/2/98 Page 10 of 11 , r - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 49 INDIAN HILL RD.CUMMAQUID Owner: JANICE BENDER Date of Inspection:11119/99 w '' NRCS Report name: Wa Soil Type: nla y , Typical depth to groundwater: n!8 . USGS Date website visited: nLa Observation Wells checked: MSL Groundwater depth:Shallow _ Moderate _ Deep SITE EXAM _ Slope _ Surface water Check Cellar �r Shallow wells ' _�• :.. a ,, , Estimated Depth to Groundwater 12 Feet Please indicate all the methods used to determine High Groundwater Elevation: - Obtained from Design Plans on record {� _ Observed Site(Abutting property,observation hole,basement sump etc.) t _ Determined from local conditions Checked with local Board of health ' f , _ Checked FEMA Maps , _ Checked pumping records _ Checked local excavators,Installers XUsed USGS Data t Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS-12+ revised 9/2/98 Page 11 of 11 TOP FNDN, AT EL. 45.0' SYSTEM PROFILE TEST HOLE LOGS - ACCESS COVER TO WITHIN 6' OF FIN. GRADE (NOT TO SCALE) ACCESS COVER (WATERTIGHT) TO ENGINEER: AH OJALA, PE MINIMUM .75' OF COVER OVER PRECAST /` WITHIN 6' OF FIN. GRADE 2% SLOPE REQUIRED OVER SYSTEM WITNESS, DAVID STANTON 41.5 • 7- 41.7 ± HILL I 2' DOUBLE WASHED P£ASTONE DATE: 5/7/02 \ RUN PIPE LEVEL �ocuS / FOR FIRST 2' - 0.75' MIN PERC, RATE _ < 2 MIN/INCH IN EXISTING 1000 / GALLON SEPTIC ' ---RE / 40.73' I & III COS (ASSUMED) 10237 CLASS SOILS P# TANK (H- 10 ) 4 7,.• RE-USE BAFFLE 40.67' �© 40.5' o CI [O C7 O 0 o O 0 0 0 39•9 000o Cl 0000 4ARouND � 00c10 0 0000 6' CRUSHED STONE OR MECHANICAL $�, 2' 0 0 0 0 37.9' 4 z COMPACTION. (15.221 123) $`� ELEV. �_% SLOPE) DEPTH OF FLOW = 4 3/4" TO 1 1/2" DOUBLE WASHED STONE�� 0�. (FAILED) 41.0' 0' Q 41.4' ( TEE SIZES: A A ROUTE 6A INLET DEPTH = 10" SL SL OUTLET DEPTH = 14" 12" 1OYR 3/2 12" 10YR 3/2 LOCATION MAP NTS B B LEACHINGLS FOUNDATION- EXIST SEPTIC TANK 30' D' BOX 13' FACILITY 5 16" 2.5Y 6/4 LOAM ASSESSORS MAP 336 PARCEL 5 Cl 10YR 5/6 LS 36" USE PERCHED WATER ELEV. OF 32.9' 48" 10YR 5/6 C Cl 2 SL SILT LOAM 2.5Y 5/4 102" 08S wATHR 32.9' 102" _ _oes WATER C3 132" 2.5Y 6/4 30.4' 138" COS C2 4 COS 150" SILT LOAM C5 10YR 5/4 156" COS 180" BLUE CLAY 186" 25.9' NO T ESI SEP IIC DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED ) 1, DATUM IS APPROXIMATED FROM QUAD DES GN FLOW; 4 BEDROOMS ( 110 GPO) = 440 GPD 2. MUNICIPAL WATER IS EXIS71NG f .I 39A USE A '44U GPD DESIGN FLOW C. M + ", . - -r - f " r,nn. i ,. s, PER F u�;T, SEPTIC TANK: 440 GPD ( 2 ) = 880 4, DESIGN LOADING FOR ALL PRECAST UNITS TO BE AASHO H- 10, j� ...-�"3 5. PIPE- JOINTS TO BE MADE WATERTIGHT. 1 1LL ��A 39,9 USE A �uuc� GALLON SEPTIC TANK (EXIST.) 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS. I jAN H 9 56' 0 LEA�H_ ING; ENVIRONMENTAL CODE TITLE V, IND 2(33.5 + 12.83) 2 (.74) = 137 7. THIS PLAN IS FOR PROPOSED SEPTIC SYSTEM ONLY AND IS NOT _ �q1 9 �B SI.)ES: TO BE USED FOR ANY OTHER PURPOSE. BENCH MARK TOP OF R 06 33.5 x 12.$3 74 - 318 8, PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC. BARNSTABLE ROAD BOUND ..- �" L��25• � 1 + .a BOTTOM: (• •••� EL. = 42.0 (ASSMD) 26' ° I LOT A EA TOTAL: 614 S.F. 455 GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT .-+ 4 /W 12" CEDA �. + 4 1 123,475f Q. FT. 14 1 USE (3) H-10 500 GAL. LEACHING CHAMBERS (ACME INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED 20 CEDAR �l FROM BOARD OF HEALTH,54t A RES OR EQUAL) WITH 4' STONE ALL AROUND 25.60 41.1 o I Irl 10. PUMP & REMOVE (OR FILL W/CLEAN SAND) EXISTING LEACH PIT L o Iwl TW1 W a AREA 0 1 4.21 +� I T� 00 PLAN TI GS E IST. r 44 I I L E GE N D + 4 4 S 44.6 1 + 3.3 TITLE 5 SITE PLAN at.l (R -USE) 4,4 EXIST. DWELL. + 40.1 � 100.0 PROPOSED SPOT ELEVATION OF a � ��� 6�"o LY 49 INDIAN HILL ROAD i' 4 4 100x0 EXISTING SPOT ELEVATION 45.0 4 IN THE TOWN OF: + 2.7 00 PROPOSED CONTOUR 1 EDAR + __ + .2 02 ( CUMMAQUID) B A R N S TA BLE o 43.8 o a1.9 , 100 EXISTING -CONTOUR PREPARED FOR: LEE HILL 40.3 CEDAR / + 41.1 6" HOLL 14" A / 0 ^, 30 0 30 60 90 A� +`200.00' 40.7 38,1 BOARD OF HEALTH Aru 4 + 40.5 MA 1 MAY 15, 2002 APPROVED r DATE: SCALE: " = 30' DATE: + 40.8 + 40.3 off 508-362-4541 fax 508 36c^-9880 5' REMOVAL OF UNSUITABLE SOIL REQUIRED I �L10 OF AROUND PERIMETER OF LEACHING FACILITY, DOWN TO SUITABLE SOIL LAYER U LJWh Cope engineering, inn, �d� ARNE H. 9G (APPROXIMATELY 11' DOWN). REPLACE WITH OJALA ARNE CLEAN MED. SAND. ENGINEER TO INSPECT AND " CIVIL H. N CERTIFY REMOVAL CIVIL. ENGINEERS 140. JAI,A LAND SURVEYORS tST ���`��� �s fc,26 e . -362 4 BR SAS 939 Main st. yarmouth, ma 02675 ARNE H. OJA A, P.E., P.L.S. DATE