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HomeMy WebLinkAbout0188 INDIAN HILL ROAD - Health 188 Indian Hill A= 336 -083 Barnstable a Commonwealth of Massachusetts Title 5 official inspection Form J�4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 188 Indian Hill Road t Property Address i :t f h Rosemary Orr Owner Owner's Name information Is Ma 02630 3111/2021 required for every Barnstable City/Town State Zip Code Date of Inspection page. Inspection results must be submitted on this form. Inspection forms may not be altered in any wa checklist at the end of the form. .Please see completeness , Y P Important:When A. Inspector Information filling out forms on the computer, Sean M. Jones use only the tab Ray to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane ¢ - Company Address Center ville Ma .02632 Cityrrown State Zip Code 774-248-4850 smjonestitle5@gmail.com, _ SI 4522 sean@smjonestite5.com License Number B. Certification 1 certify that: 1 am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); I 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 l have determined that the system: 1. Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority i x 4. ❑ Fails 3/11/2021 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. t t5inap.doc•rev.'MU2018 Title 5 ofncial Inspection Forth:Subsu face Sewage Disposal System•Page 1 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 188 Indian Hill Road Property Address Rosemary Orr - Owner Owner's Name information is required for every Barnstable Ma 02630 3/11l2021 page. Cityfrown 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 property located at 188 Indian Hill Rd Barnstable js served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box and a precast leach pit. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 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. r- "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 t5lnsp.doe•rev.7MM2018 Title 5 Off del Inspection Form:8ubsurfeoe Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Insp-ection ® ­ Subsurface Sewage Disposal System Form-Not forVoluntary Assessments 188 Indian Hill Road Property Address Rosemary Orr Owner Owner's Name information isBarnstable Ma-. 02630 3/11/2021 required for every page. Cltyrrown State Zip Code Date of Inspection C. Inspection Sumrnaky (coat) 2) System Conditionally Passes(cont): �] Pump Chamber pumps/alarms note 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): u broken pipe(s)are replac d, R Y ❑ N [] ND(Explain below) obstruction is removed 0 Y ❑ N E] ND;(Explain below):-, distribution box is leveled)orreplaced n Y ❑ N E 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 F1 Y ❑ N. ❑ ND(Explain below): ❑ m 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 pratect Public health, safety ry or he environment. a. System will pass unless.Board of Health determines to accordance with 310 CMR Protect 15.303(7)(b)that the system is not functioning in a manner which will public health, 4 safety and the environment: t5insp.doe•rev.7/26t2018 Title 5 Official Inspection Form:Subsurtece$swage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments 188 Indian Hill Road Property Address Rosemary Orr Owner Owner's Name information is Barnstable Ma 02630 3/11/2021 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cost.) 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: El 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 I 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 E ® 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 t5lnsp.doc rev.UM2018 Idle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection .Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 188 Indian Hill Road Property Address Rosemary Orr Owner Owner's Name information is Barnstable Ma 02630 3/11/2021 required for every State Zip Code Date of Inspection page. City/rows C. Inspection Summary (cant.) 4) System Failure Criteria Applicable to All Systems:(cost.) Yes No ❑ ® 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 ❑ ® 7 than /2 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 water supply well. ❑ ® Any portion of acesspool 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.] 1 ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ❑ ® The system falls. 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 El ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well Mnsp.doc•rev.7f2812018 rdle 5 official Inspection Forth:Subsurface Sewage OWPOSal System'Page 6 of 18 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System form-Not for Voluntary Assessments 188 Indian Hill Road Property Address Rosemary a Or r Owner Owner's Name information is Barnstable Ma 02630 3/11/2021 required for every page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary (cunt.)' If you have answered"yes"to any question in Section C.5 the system is considered a significant threat or answered Y "ye s"to an 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 C.4 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 ® ❑ 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: ® ❑ 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)) i 'P I 6 '4 t5insp.doe-rev.7f262618 Title 5 Official by pedon Form:Subsurface Sewage Disposal System•Page 6 of 18 F Commonwealth of Massachusetts Title 5 Official Onspection Fonii Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 188 Indian Hill Road Property Address Rosemary Owner Owner's Name w information is Barnstable Ma ° 02630 3/11/2021 required for every CityRown g Zip Code Date of Inspection page- D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 , DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Description: 0 Number of current residents: Does residence have a garbage grinder? Yes ® 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 ® No Seasonal use? ❑ Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): Detail: m . ❑ Yes ® No Sump Pump? , unknown t Last date of occupancy: Date i It - t5lnsp.doc• Title 5 official Inspection Form:Subsixracs Sewage Disposal System•Page 7 of 18 rev.71Y8MIB Commonwealth of Massachusetts Title 5 Official - Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 188 Indian Hill Road Property Address Rosemary Orr Owner Owner's Name information is required for every Barnstable Ma 02630 3/11/2021 — State Zip Code Date of Inspection C' 1Town P Pe page. City frown System Information (cone.) 2. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No 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: Tank pumped for inspection Was system pumped as part of the,inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? size of tank Reason for pumping: routine maintenance 8 .aoc rev.�nenol s Time 5 official Inspection Form:Subsufaoe Sewage Dispose)System•Page 8 Of 18 • f '� g Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 188 Indian Hill Road Property Address Rosemary Orr { Owner Owners Name { infonnabon is required for every Barnstable f Ma 02630 -3/11/2021' page. City/Town State . Zip Code Date of Inspection D. System Information (cont.) _ _ t 4. Type of System: ® Septic tank, distribution box,soil absorption system,, r 4 a w El Single cesspool Nkowecesspool , Pnvy Shared system(yes orno)(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, i m ❑ Tight tank.Attach a copy of the DEP approval. ❑ C1her(describe) Approximate age of all components, date installed(if known)and source of information: Original system.installed 5/12/1986,d-box replaced for inspection permit#2021-063 . Were sewage odors detected when arriving at;the site? ❑ Yes ® No 5. 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.): u Joints it good condition, no leakage,vented through roof. tsnv.doc•rev.MOWS " TRW 6 OfWW Inspection Form:'Subew fam$swage Drsposal system•Page 9_of 18 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 188 Indian Hill Road Property Address Rosemary Orr Owner Owner's Name information is required for every Barnstable Ma 02630 3/11/2021 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1 feet Material of construction: ED concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain) If tank is metal, list age:. f year Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) C Yes ❑ No Dimensions: 1000 gallons Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle Scum thickness M Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle w How were dimensions determined? Tank pumped for inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank was pumped for inspection and should be done again every 2years for proper maintenance. ffilmp.doc•rev.7128W 8 Title 5 Off dal Inspection Forth:Subsurtace Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 188 Indian Hill Road f y Property Address Rosemary Orr Owner Owner's Name information is Barnstable Ma 02630 3/11/2021 required for every State Zq)Code Date of Inspection page city/Town D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal (]fiberglass ❑polyethylene ❑other(explain): Dimensions: Scum thickness r 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.): B. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction; 0 concrete ❑metal ❑fiberglass . E polyethylene (]other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.dnc•rev.MAW 8 Tdb 5 ofrraial Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Foam Subsurface Sewage Disposal System.Form-Not for Voluntary Assessments 188-Indian Hilt Road Property Address Rosemary Orr - Owner Owner's Name information is required for every Barnstable Ma 02630 3/11/2021 Ci /Town page. tY State Zip Code- Date of Inspection D. System Information (coat.) 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.): ry. "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0° 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.): d-�box replaced for inspection permit#2021-063 tgnsp.dw•rev.U25018 Title 5 Official Inspection form:Subsumfaoe Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 188 Indian Hill Road Property Address Rosemary Orr Owner Owner's Name e information is 11 1 M 02630 , 3l /202 required for every Barnstable Ma C' /Town Date of Inspection State - Zip Code page- D. System Information cunt. 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes E] No` Alarms in working order: ❑ Yes ❑ No' Comments(note condition of pump c amber, condition of pumps and appurtenances,etc.): i I I 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: I Type: ® leaching pits- number. 1 leaching chambers , number leaching galleries num ber ❑ leaching trenches number, length: - El leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5irsp-doe•rev.7121id2018 -rdle 5 official Inspection Form:Subsurface Sewage Disposal System-Pap 13 of 18 M i Commonwealth of Massachusetts Title 5 Official Inspection Fora ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 188 Indian Hill Road Property Address Rosemary Orr Owner Owner's Name information is required for every Barnstable Ma 02630 3/11/2021 page. Citylrown 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.): Leach pit was found with 6 standing water and a stain line approx 4' higher. 12. Cesspools(cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration — Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.M612o18 Tale 5 official Insp ection Form;Subsurface Sewage Disposal System•Pege 14 of 18 P Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 188 Indian Hill Road Property Address Rosemary Orr Owner Owner's(dame information is required for every Barnstable Ma 02630 3/11/2021 City/Town page. State Zip Code Date of Inspection D. System Information {cont.} 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs'of hydraulic failure, level of ponding,condition of vegetation, etc.): t5inap.doc•rev.72fi/Z018 Title 5 Official Irmpectim Form:Subaurteoe Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 188 Indian Hill Road lvf Property Address Rosemary Orr Owner Owner's Flame information is Barnstable Ma 02630 3/11/2021 required for every _ page. Cityrrown 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 Q A 3v`6 \3I t5insp.doc•rev.MM2016 Intle 6 Ofridal Inspection Form:Subswfaw Sewage Disposal System•Page 16 of 16 r - Commonwealth of Massachusetts Title 5 Official Inspection Foy Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 188 Indian Hill Road Property Address - Rosemary Orr Owner Owner's Name information fb a Barnstable Ma 02630 3/11/2021 required for every page City/rowfn state Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high groundwater. 1 feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: Checked with local excavators, installers (attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t%W.doe•rev.7/26=18 Me 5 Official Inspection Forth:Subsurface Sewage Disposal system•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 188 Indian Hill Road Property Address Rosemary Orr Owner Owner's Name information is required for every Barnstable Ma 02630 3/11/2021 page. Cityfrown State Zip Code Date of inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: 0 A. Inspector information:Complete all fields in this section. ® B. Certification: Signed&Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 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 t51nT.d=•rev.7f26/2078 Title 5 offie l Inspedim Form;Subsurface Sewage '� D mposat System•Page 18 of 18 No. c>Q`Z u-S Fee— ✓— THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes application for ]Disposal 6pstrin Construction 3pPrmit Application for a Permit to Construct( ) Repair(/ Upgrade( ) Abandon( ) ❑Complete System ndividual Components Location Address or Lot No. \ ''r/� C%^ I Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 3`—b 3 Installer's Name Address,and Tel.No. Designer's Name,Address,and Tel.No. -tloki M =rw�Y., k k 3 o t d kc T 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 Nature of Repairs or Alterations(Answer when applicable) ��r4(,,( QA �S 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 He rr'' Signed Date e�J I / V Application Approved by Date di Application Disapproved by Date or the following reasons Permit No. a d`� V Date Issued r r f� ..No. c� `� i tl 6C� 'ell Fee uteri ��-�' �� "• THE COMMONWEALTH OF MASSACHUSETTS Entered in comp -"� PUBLIC HEALTH, DIVISION` TOWN OF BARNSTABLE, MASSACHUSETTS YeS `t application for Misposal 604trm,Construction Permit N ' ... - ,...•., ;" .�" *'r Application fora Permit to Construct( r Repair(U/ Upgrade( ) Abandon(' ). Complete System [0.In�idual Components Location Address or Lot No. l �$ r, O�^ 0 %\� Owner's Name,Address,and Tel.No. r 33 Assessor,'s Mapfarcel Installers Name ddress,and Tel.No, V Designer's Name,Address,and Tel.No. 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 ._ - *i E Size of Septic Tank Type of S.A.S. Description of Soil --- Nature of Repairs or Alterations(Answer when applicable) ©�,n k r-r F aM .e- , \e 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 Health. Signed Date 3_ Application Approved by Ilk �( � / ,, Date 7 (/4L f Application Disapproved by \! Date for the following reasons Permit No. O ( '" 4? t Date Issued Vb ( „ THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS tj d`W Certificate of Compliance j,THIS IS TO CERTIFY,that the On-site Sewage Disposal,system Constructed( ) Repaired( �)� Upgraded( ) Abandoned( )by c o V_ —`at" ('Z_'C{ has been cotistt�icted in accordance / j with the provisions of Title 5 and the for Disposal System Construction Permit No.2.gd ( -df;;dated 7/V/ r ` Installer c0 ('t ",N..14 Designer ! // #bedrooms k f 1 .A- ` Approved design flow �,!n' gpd The issuance of this permit hall not be construed as a guarantee that the system will o�as designed. Dates ,� ) �" Inspector �A� -✓"�..,. : Fee ` THE COMMONWEALTH OF MASSACHUSETTS ` PUBLIC HEALTH DIVISION-BARNSTAB)LE,MASSACHUSETTS - Mispo8al *pStt/em Construction Permit Permission is hereby granted to Construct 1( . ) Repair(Jt ) !1 Upgrade( ) Abandon( ) System located at A C 1 l(AA 41-4 d. 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 localprovisions or special conditions. Provided:Construction must be completed within three years of the date_of this permit. Date PP A roved by I Vk , r � k, 10 CATION S E W A G E PERMIT NO,. LoT ► i m DiAN .N t u. eo g6 - V3 I VILLAGE COMMAUID ® INSTALLER'S, NAME b ADDRESS Cue. Cc ti4c. IAAR-Wlcti MA . B UILDE R OR OWNER POLK A55oC . (1-A"A") ymmcoTk Po p-T M&ss. DATE PERMIT ISSUED -;l / 2®� , DATE COMPLIANCE ISSUED Fa*Ml AF7 Vol So�rrt•+ S�D� 0- To 'T�.iS� t8�� tnoo {iex, Pir go 54 B _ To -ra+•t�. • 24•s Q ?o P 3 S jam'. ,� '� 12 — `6, � � r `k• 11,10V No.r...... `�...�:: .� Fps.` THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH �._ I ......OF........ ,•' -�2 ', _f_'F E3-•L•....................... i 0 9 r�' 2�Application ApplirFa#ion fur Disposal arks Tonstrurtion rrutit is hereby made for a Permit to Construct ( Vj"or Repair ( ) an Individual Sewage Disposal System at: Location Address / or Lot No. . Owner _ Address CD or F •............... Installer Address Q Type of Building Size Lot...........,............ 7.S q. feet Dwelling—No. of Bedrooms............. ..........Expansion Attie-jam Garbage Grinder--(�j '79:�- �--__.... No. of persons &............... Showers Cafeteria Other—Type of Building p ..(�}--�- {�— Q' Other fixtures W Design Flow........................:t-�. gallons per person per day. Total daily flow............�q.;K.g.............gallons. W Septic Tank—Liquid capacity/-®5?.gallons Length-?__._e-!' Width.. .......... Diameter________________ Depth....... �.. x Disposal Trench—No................:... Width.................... Total Length.................... Total leaching area....................sq. ft. v Seepage Pit No.......... ________- Diameter....... Depth below inlet......47... Total leaching area....z.-1-sq. ft. Z Other Distribution box ( Yj Dosing to (`�•>4 � `" Percolation Test Results Performed by.... ....�nr _� ... ���_ ____________________ Date._.._ f../--............_..`. Test Pit No. 1......�.....minutes per inch Depth of Test Pit-----Z._____.. Depth to ground water.......... f=, Test Pit No�....xr_...minutes.per inch Depth of Test Pit..... Depth to ground water....... .�.�� ------------------------ ---•--•-----•------•..........._/ - .............................. Ox Description of Soil.........T!�.n 1 0, "-r-� - ` ` C" ! . . . ---------------- -- _ ------------- ...................................•--- 3. . . o W -•---••-•••-•--------------------------•---------------•--••--•••--•---=---•------••------------••--------•--•----------.....------------•-•--•--•----------------------••••-•-•-•--•-••-•-----•••-_.... UNature of Repairs or Alterations:, Answer when applicable................................................................................................ --------•---------•---------•-------------------------------------------------••--••--•---.. --•-•• -------•-------••------••-- •--•----•----•-••----••-•-•-••-•-------•--•--•----------•--••-•••---- Agreement: The undersigned agrees to install- the aforede cr' ed Individual e ge Disposal System in accordance with the provisions of iITL iE 5 of the:State Sanitary Co The unders ne further agrees not to place the system in operation until a Certificate o ompliance has been ' d b e b 1 'Z//3�/ S1d. ...... ..................... ................................................... .••-•••-•---Date........_.... Tication Approved By. Date Disapproved for the f o ing reasons:--------------••----•-•---------------------•----------•----••-----------------•---•----•-...--•------...._.._ L ---------------------•-----...................--••-•---------------------.....:_......---------..--....--•------•----•----------•-•-------•-----•------------------------•------•-•••-••-••----••-•••--- Date PermitNo........Cd '._...� ....................... Issued..................................................... Date r No........................ Fim............._... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Td vvlVl.._.......OF........ ' ...........................c.r✓ -S �� L ApplirFa#ion for Disposal Works Towitrnriiun erntit Application is hereby made for a Permit to Construct ( kl'or Repair ( ).an Individual Sewage Disposal System at: , 1- n 7-- s 7 v/, G , , /�, I/ �;JA/j �/gas e 360n e- ................--------- ------------- - ....... -----------... e _Lr tion-f�Address O r or Lot No. ......................».... ....- ....---• ------• --------• ....._.. ------------------- •---------- .....-------- O _ A d ss ---------------•---------•-----......... -•-- .-. ---•-.------------.----_.--.---------------- .........--------. "-------- ...V. Installer Address 6 32 q UType of Building Size Lot•-_._---.__�............Sq. feet a Dwelling—No. of Bedrooms... �-__-_-••--•-•...............Expansion,Attie-(''"�� Garbage Grinder� p-, Other—Type of Building ........................ No. of persons............................ Showers-�-' Cafeteria �� dOther fixtures t-•-•- ..........=-•------•---•------------•-----•-•-------------------•---------- ----..................... W Design Flow............................................gallons per person pqr day. Total daily flow----......._.__.....__.._.._._______-•......gal1np. bT `T 9 Septic Tank-Liquid capacity�O°.gallons Length................ Width__-......��_. Diameter................ Depth................ ' Disposal Trench—Nq.--•----------------- Width.................... Total Length.............. Total leaching area......,...• �-sq. ft. Seepage Pit No..................... iameter.......!2__..._. Depth below inlet..3.:..5-..... Total leaching �_._...sqj ft. Z Other Distribution box ( Dosing t �--�) 3 l �a�(wvrI/ r, e.f) c (��i / 82- ' 'i Percolation Test Results Performed by.................................................. .................... Date...._____................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water....... 44 Test Pit No. � / 6 0 �3,.____An_._minutes per inch Depth of Test Pit____________________ Depth to ground water......................... O Description of Soil----..-..r_'_''___ _;/ -�•� e }j v v i s Q = J .Q y_P r s ••------------------------ -------•-----•-•------- -----=.........: .......... -------C.../cam.. �. V'rJ -------------------------------r_... w ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable,.............................................................................................. .......-............................................................................................................----•--------••---•-••-------•-•••-•---••--------------------•------..........•-•--- Agreement: The undersigned agrees to install the aforedes rib I I dividual S a e Disposal System in accordance with the provisions of LI IE 5 ok,the State Sanitary Coe ndersi urtlier grees not to place the system in operation until a C-rtificate of compliance has bee ed t boa o i lth. fcation i -•-•----��• --•---Ap Approved BY .._.. .._.... ........... Date ....... Ap¢lication Disapproved for the f of ......ing reasons:........................................ --•---•--•------•----------------•------..._...................._ ................•--•----...-•-•---•----..........--------=•--•--•--------------......_.............--------•-•••-•----•-•------•--•••--•-•-----•-•--•-----•------•---••••-......-•-------.......--••-- Date PermitNo....................... ...................... Issued....................................................... ' Date THE COMMONWEALTH OF MASSACHUSETTS 4 BOARD OF HEALTH ....................................OF............................. .............................e................... C�rr�if irtt�e of f�nnt��innre � THIS IS TO CERTIFY. That the Individual Sewage Disposal System constructed ( �f'Repaired ( ) by-.-------------•-- ----------------•----_-`:......... ................•--••--------- ----- •-•--------...... .------..........---........... at••-•--�--Q-r......... _r— r7 V ` ¢[ n �•l I5;t filer .r�c� �/ , 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------- 0..., j_�_.__.___. dated...... Z6-kE ---------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. ;. DATE...�::`�� .Il Z�� �..-•• •-•..................••----•--...._. Inspector--••--............-----------------•-•-••-•-----------...---------.................. i THE COMMONWEALTH OF MASSACHUSETTS �rsnS•}12�C��''1 , uxr,�e 10AIC.r BOARD OF HEALTH �G ..�... ..�....OF...... � cl '� ... �L� ..................... No.................... FEE........................ i4oliall Workv, U141 it Vamp Permissioni hereby granted�-•------------------------------------•-••--.---P---...........-----......----..._....------------............................----... .. to Construct L or Re air. n Individual Sewage DIS, osal stem/ at No....... / � c� - f �/ �, d� C ✓,r->,� v s, ....................•--•---------•---------•---------•----.....---•------------------------------•--- .......................... ....... -----.1.............. .' Street 76—13 �. Zapve as shown on the application for Disposal Works Construction Permit No____ __ t__ D ed_._.._. ... . ___ _,....__._........ *4 d' .............. ..._..... .__..._..___......____...... ....... 4 Board of Health DATE............ 9 FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS oo __ p ❑ Box 757, East Dennis, Massachusetts 02641 (617) 385-2831 May 22, 1986 Mr. John Kelley Barnstable Health Dept. Barnstable Town Hall 367 Main Street Hyannis, MA 02660 RE: LOT 1 INDIAN HILL ROAD CUMMAAUID Dear John: This is to certify that on April 24, 1986 I inspected the construction of the subject septic system after the leaching area had been excavated 16 feet deep confirming the presence of sand and absence of any water. Also, I inspected it after installation of the system and prior to backfilling. Since the hole was excavated 16 feet without hitting water, the .installer field the invert but used a 1000 gallon pit instead of the proposed 600 gallon pit . This puts the bottom of the leaching pit 7 feet above the bottom of the excavation. In my opinion, this will provide added capacity without any adverse affect. Otherwise, to the best of my knowledge, the instal.lation substantially agrees with my design and meets Title V and Barnstable Health Regulations. Sincerely, Cr R. Short, PE CRS:ps CC's: Joe Gomes at Robert Our, Inc. Don Swanson ENGINEERING o SURVEYING o DESIGNING o BUILDING I VC mI t number: UaIc: .c, Completed by jt S — - -- HIGH GROUND-WATER LEVEL COMPUTATION Site Location: -�n� e4� �,-l� e 'C v •.-�. .�+� � �� Lot No. Owner: all.- tw'a rrdt Address: Contractor: Dew .S "y-ca -T40 p Address: N I t e s: Gl eX. i U_S itQ ! -,1 e4.e1 .a o- .6 o ✓ a. GdrA cot- !If-r. -F . 7 h STEP 1 Measure depthoto water table to nearest. ]/10 ft. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. (0/ / / Is date STEP 2 Using Water-Level Range Zone and Index Well Map locate site and determine: Sr> vw 2SZ A) Appropriate index well . . . . . . . . . . . . B) Water level range zone . . . . . . . . . . . . r=� SITEP 3. Using monthly report"Current Water Resources Conditions" determine current depth to 4 water level for index .well . . . . . Z. mo yr i STEP •4 Using Table of Water-level Adjustments for index well STEP 2A , current A pth. to water level for index well _ (STEP. 3) , and water-level zone (STEP 2B) determine water-level adjustment . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . STEP 5 - Estinate depth to high water by subtracting the water- level adjustment (STEP 4) from measured depth to water ,F level at site (STEP 1 ) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . j • f /s9 Ss 0 APPROVED JUL 0 8 2015 Town of Barnstable ¢ Old King's Highway Committee Q aaa; f J D ell 4 N a - J RE BU LT ` P DUCK D CERTIFIED PLOT L 0 C AT 1 0 N: COA11 f U/OPLAN �Q .gi2ASTi��g�� ss. FOR: SCALE: � = ��� DATE: /c�C�. Z6 198� R E F E R E N C E: �3,E/�G G o 7-/ As s Now o.✓ �Gi9.�/.eEGO 20L O i9 T,�3�92�5 i�9 C3�-E ,e I CERTIFY TO THE BE.S'T OF MY KNOW ( R �r 'AND BELIEF FROM INFORMATION ACptS-(eE ' EG• LAND SU EYOR THAT THE foU�/0�7-/p,J SHOWN ON THIS PLAN IS LOCATED ON THE GRO/UND AS SHOWN HEREON. � �Zt4 4f ' JOSS PH ` � �/A N MONAHAN, J R.J M : M O N AH R B ASSOCIATES 1ssat . . E IP R.OFES.S I ON A L LAND SURVEYORS .& EN.GL.NE.ERS �; _ "'c FrfsTER�°� q` ,&-OWN.-E...PLAZA . 900 .ROUTE 1..34r.S.0UTH ..D_ENN.LS1*._M.A_$.S... Ne St1R�� SOI L LOG DATE: !� ✓ ` ! ` WITNESSED BY 7 - -77 Zsaj 4- i o � - 6t 4 (� 5 41 N d -,-- FL 2 9'.0 gg s 4- 4 a n i ,v :, 7`--C `` C �JN r- -- ► �ELEV TOP OF AAANHOLES AND COVER TO BE BUILT WITHIN 1 2" O F FIN I S H E D G R A D E FOUNDATION ' ' 3 ry. Ft -- AA I N 2 � SLOPE NISHED GRADE `` 1 ` 0 4!'CAST I RO 0R •' . :.•... . 4, PVC SC 40 ' 1ST ' , PVC SCH 40 __ %✓ PITCH I/,4 FT � 2` LEVEL, 10„ MIN. 2" LAYER - 1�8 1/2 PEA S TO N E c r L W�.N >?FP t 3 �, p P I p C H . �ij„✓ , �, - - I 4 1>e z"FS r --- — o.o, 1�4 F -5' D _ p 34' ''� 1 NVERT e {N4=-S T GALLON INVERT DIST INVERT' ,. D i N a p ' PROPasg� vER 3G,C?c, gpX ^O , - I If2 DIA . Y " 27 rs, SE PTlCTANK 3S �'"i < � O 34 r.... ..,. : INVERT ---' .D �1 V tp" ASHED STONE I �rh2. D w t c t J / fir, F/V +s, i f`1 _ LEA7)cj-t �y L'=2 T� °' •� INVERT �.Q w p,' ALL AROUND k 3 ' s / L q' K �s' r pl T r y. /1 5 f ��- F X ,�?�. T f tJ nfi 1,s.I� ` 0 GARBAGE ° tL W [�" a _ • ' PTA I O: TG� L w,�ry) oLl T 4 �" M i N . G R I N D GE R -..__..� _.� .. °� ! E LE V. 8 0 T T 0 U I .,.., �,--� r �...r- __-__ —.. - _____._.�_. .____._...�.__._ _ _ _ ' . __ ._ _ OF P IT } a a ^- �c /? Z�/ ' F-!!Jt-3— tl ? C?' ►..y ►v -�+• ('D I A---4 ~�-t at ( /-7 p,T v .5 T D f)MN.,t#• *- E - ` PROFILE OF GROUND VVATER' TA 19-L F w , rti CLti SAN ITARY DISPOSAL SYSTEM 5 � NOT TO SCALE DESIGN DATA f � � AlV ��• ,� � '�,c- � ".�' � BE © • CONSTRUCTION OF SANITARY DISPOSAL BEDROOMS ' DESIGN FLOW 3 ' (D GAL ./DAY (s ^ �� � �' Lev✓ �7RF",►='� �7"ra SYSTEM SHALL CONFORM TO MASS . � � � - .f � Lam. LEACH RATE L 2 MIN./INCH , ENVIRONMENTAL CODE TITLE V (REVISED 7- 1 -- 77� PROPOSED LEACH CA PAC IT Y AND THE TOWN OF L3.�.Jz AJ -r-F4d:�--F HEALTH REGULATIONS . - • SEPTIC TANK, DISTRIBUTION BOX AND LEACHING PITTO BE OF REINFORCED CONCRETE : 44 = GAL/DAY MIN. CONCRETE STRENGTH 3000 PSI MIN. STEEL 5TRENGTH 2O,O OOP SI H 10 DESIGN LOADING • DRIVEWAYS NOTTO BE LOCATED OVER SYSTEM UNLESS H - 20 DESIGN LOADING IS USED. ALL PI PES AND FITT I NGS TO BE WATERTIGHT AN D TO BF OF CAST IRON OR SCHED 40 P.V. C. SIT L. PLAN SHOWING PROPOSED (ZONSTRUCTION SH . QF ,r SHS LEGEND L 0 C A T ( a I`! a_ 11-S 7- )ZI Z. � /v F rti I r-r "P _ F 0 R I Z C.),?3 1?T t� C7 J-Z LD APPROVED 19 _. ----- SCAi- E: ) if _ 40 DATE : _2/� � G� REy 2/i8/6 BOARD OF HEALTH BUILDING SETBACK REGULATIONS PER EXISTING CONTOUR - --16--- REFERENCE: L- colr- ,1 x4s s � ow^r i -,✓ BUILDING INSPECTOR OR BUILDPNG COMMISSIONER . ZeL"E- 7 � - Z PROPOSED CONTOUR t6 �' �� 2g / p� DATE AGENT MIN FRONT SETBACK 301 EXISTING SPOT ELEVATION 17. 6 MIN. SIDE SETBACK 16 PROPOSED WATER SERVICE yy _ � ��ytOF MIN. REAR SETBACK 16, TEST HOLE LOCATION (2+ f o �1 m t 1 . L.- 40 7- S 4.3 Zc%4 0 .� `1K�o. 2,483 mot' t C . R . SHORT, INC . _ , � FPI $r� � �L n V t/ PROFESSIONAL LAND SURVEYORS a ENGINEERS `-._,hatF:i 1586 MAIN STREET �RTE 6A,'' EAST DEr"tiNIS, MASS . 02641