HomeMy WebLinkAbout0074 PIN OAKS DRIVE - Health f . 74 Pin Oaks Drive
Bamstable
9 '9
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11
No. �� G d-( Fee UU—
THE COMMONWEALTH OF~MASSACHUSETTS Entered incomput :
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2ltlfltation for ]Disposal bpstem Construction permit
Application for a Permit to Construct( ) Repair� Upgrade( ) Abandon( ) 0 Complete System ❑Individual Components
LIM
ess or Lot No. i ( , Owner's Name,Address,and Tel.No. �(p j7•, 3
p/Parcel a ) 14
Ad s,an 'Tel:Noss'O$-yo7� t!o Designer Name:Address,and Tel.No:SG$" o '
�Ons� ci",milc_• v,Box 7vV
Type of Building: -
PAW
O
Dwelling No.of Bedrooms S Lot Size 70,,C�sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers'( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3'`�(� gpd Design flow provided SloO gpd
Plan Date .7' Number of sheets Revision Date
Title ^ 6 A
Size of Septic Tank Type of S.A.S.
Description of Soil� 1". kit-
Nature of Repairs or Alterations(Answer when applicable) l5� -e-�
��
Date last inspected: f
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 a the system in operation until a Certificate of
Compliance has been issued by this Board.of'
Si Date lf� .t
Application Approved by Date It 2.
Application Disapproved by Date
for the following reasons
Permit No. $ r 3 Date Issued
THE COMMONWEALTH OF..'MASSACHUSETTS a +e
BARNSTABLE,MASSACHUSETTS 3
Certifitate of �Cornpfiante.
THIS IS TO CERTIFY that the, On-site Sew e-Disposal system Constructed( ) Repaired K ) Upgraded
Abandoned�12
)by r f `: 7 .{ '7G
at .`,� n-►&k111) Dr' � � ,.XT- has been constr�uycted in;accordance s
with the provisions of Title 5 and the for Disposal System Construction Permit No; o�y l' C� dated
i j i 1: f"
Installer r11 t`GL/t t n 1 ? .171 Designer �(if�r,S� �i�7 f . c ,y t�p> n
#bedrooms Approved design flow= �� gpd
The issuance of this permits 1, t be construed'as a guarantee that the system wil as igned
Dates Inspector.
. y
------------
N° �r u Fee PJ
s .,
THE COMMONWEALTH OF MASSACHUSETTS'` 4 r'
PUBLIC HEALTH DIVISION-'BARNSTABLE,MASSACHUSETTS
{
is osai pstent Con$truttiou J)ermit + 1
1
Permission is hereby granted Construct( ) Repair(�jr Upgrade( ,) Abandon-(
r'System located at ✓ l . f�i 2 f � �� F
r
0.1
and as described m the above Application for Disposal System Construction.Permits.The applicant recognized his/her duty:o comply with
Title 5 and the following local provisions or special conditions.
Provided Construction ust be completed within three years of the date=of this permit �•'
Date �Z % Approvedby I` .
DEC-11-2021 00:07 From: To:15067906304 Pa9e:1/1
Town of Barnstable
Inspectional Services
I I Public Health Division ,
Thomas McKean,Dlrector .
200 Main Street,Hyannis,MA 02601
Office: 508;862A644 Tax: 509-990-6304
1
Installer&Designer Certification Form
Date: Sewage Permitf o7OA l - 39 Assessor's Map%Parcel
Designer. IM MMU?. 2( a C. Installer: /CO nSh (b_'_6L4 1 rLC.
Address: 93q p%tK tgpf� Address: 'WZexAS IV
-=Y I armo 1- �u r�
on i/ i'� �L/� was issued a permit to install a
(date) (installer)
septic system at -74 Pt'h Oa V-S D r. PRr11 Stab l'.-. based on a design drawn by
(address)
bo
o' G, dated
(designer)I�p 5
A certify that the septic system referenced above was'installed substantially according to
the design,which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank Strip out(if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10, lateral relocation of the SAS or any vertical relocation of any component
.of�the septic system)but in accordance with State&Local Regulations. Plea revision or
certified as-built by designer to follow. Strip out(if required)was inspected and the soils•
were found satisfactory.
I certify tha tern referenced above was constructed i M ce with the terms of
the pmv letters(if applicable) °f ss4.
DANIELA. ,
OJALA
CIVIL `"
nS eI's Signature) p No,A8S06�
GIST
FS510NAlE-G
(Designer's Signature) Affix Designer's tamp,Here)
PLEASE RETURN TO BA STABLE PUBLIC HEALTH DIVISION. CERTIFICATE
..tee. .a�.,ns,► AND �r
OF CO LIANCE.WILL NOT BE ISSUED U 11L B � �ruS FORM A D AS-
BUILT C RECE VED-BY THE BARNS AB PUBLICHEALTH-DIVISION.
THANKOU.
WoaWep{f EALIMEWFRoonnCCASEPTJ00uJgnerWIflaa0onFormRev&M-13.000
7/l/2020 Full-Size Document For 2nd floor plan
2nd floor plan
74 Pin Oaks Drive, Barnstable, MA 02630
This listing is Active Listed for$3,499,000 MLS#21905583
pp I * -
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7/1/2020 Full-Size Document For ist floor plan
!st floor plan
74 Pin Oaks Drive,Barnstable,MA 02630
This listing is Active Listed for$3,499,000 MLS#21905583
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TI A -
S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
fy
Subsurface Sewage Disposal System Form Not for Voluntary Assessments - t
., � 74 Pin Oaks Dr. ,
emu— ---- - — --
Property Address
Ama Torenc_e' Davies
Owner Owner's Name _ -
,,
information is Barnstable ✓ Ma. 02630 2-10-211.
required for every -- -- - =-----
page. City/Town State Zip Code Date of Inspection +;r"
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
y
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Jim The Inspector Man
use the return
key. Company Name .
P.O.Box 784
rep Company Address
_West Yarmouth _ _ _ Ma. _ 02673
City/Town State Zip Code
508-364-4398 _ _S114430
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: t
1. ® Passes
2. ❑ Conditionally Passes
MICHAEL '•N
3. ❑ Needs Further Evaluation by the Local Approving Authority' =o: SEARS
* No.S114430
4. ❑ Fails
RTIf�
INt
wPi 2-10-21
Inspector's Sig ure 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
F Title 5 Official Inspection Form
w
, Subsurface Sewage Disposal System Form Not for Voluntary Assessments
74 Pin Oaks Dr.
u- Property Address
Ama Torence' Davies
Owner Owner's Name
information is required for every Barnstable _ Ma. 02630 2-10-21
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:
System is in workingorder _
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 exfiltratiori or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the-Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking_ and if a Certificate of
Compliance indicating that the tank is less than 20-years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/23/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Pin Oaks Dr.
0 Property Address
Ama Torence'_Davies
Owner Owner's Name
information is required for every Barnstable Ma. 02630 2-10-21
_ -� --- -----
page. Cityfrown ' 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):
n 4 times a year due to broken or obstructedpipe(s). The
❑ The system required pumping more than - t e y
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 P 0 Dr.in Oaks _
Property Address
A_ma Torence' Davies
Owner Owner's Name
information is Barnstable Ma. 02630 2-10-21
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:
i
**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
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
1 .. o Title 5 Official Inspection Form
<�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 74 Pin Oaks Dr.
u _
Property Address
Ama Torence' Davies
Owner Owner's Name
information is Barnstable Ma. 02630 2-10-21
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
❑ ® 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 1/z 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.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified .
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure. F
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 C.4:
Yes. No
M ❑ ❑ the system is within 400 feet of a surface drinking water supply
IIII ❑ ❑ 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 11 of a public water supply well
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- �i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Pin Oaks Dr. _
u� Property Address
Ama Torence' Davies
Owner Owner's Name
information is Barnstable Ma. 02630 2-10-21
required for every — -
page. Cityr 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
❑ ® 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)]
t5insp.doc-rev-7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
In Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
74 Pin Oaks Dr. _ _ —
u� Property Address
Ama Torence' Davies__
Owner Owner's Name
information is Barnstable _ _Ma. 02630 2-10-21 _
required for every Y
page. Cit /Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
• 5
(design):Number of bedrooms desi n): 5 Number of bedrooms(actual): --
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
Description: F _
- 4
Number of current residents: 0
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? El Yes -® No
-Water meter readings, if available (last 2 years usage (gpd)): NA
Detail:
Sump pump) ❑ Yes E No
NA
Last date of occupancy: Date
t
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
1p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
74 Pin Oaks Dr.
Property Address
Ama Torence' Davies _ #
Owner Owner's Name
information is Barnstable Ma. '02630 2-10-21
required for every
page.
City/Town State -Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc):
Grease trap present? ❑ Yes ❑ No
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:
NA
Source of information: —
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons -
How was quantity pumped determined?
Reason for pumping: ---
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Pin Oaks Dr.
Property Address
Ama Torence' Davies
Owner Owner's Name _
information is Barnstable Ma. 02630 2-10-21
required for every -- --- - -- -- -- --_
page. City/Town State Zip Code Date of Inspection -
D. System Information (cont.)
4. Type of System: r 4
❑ 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:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 22" --
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.):
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
+� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Pin Oaks Dr.
Property Address
A_ma Torence' Davies
Owner Owner's Name
information is Barnstable Ma. 02630 2-10-21
required for every - ------------T---- -- -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: --
Sludge depth:
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 -
Distance from bottom of scum to bottom of outlet tee or baffle —
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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
c1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!j 74 Pin Oaks Dr. _
u Property Address
_A_m_a T_orence' Davies
Owner Owner's Name —~----------------- . .�_. _._-_
information is Barnstable Ma. 02630 2-10-21
required for every —
page. City/Town State Zip Code Date of Inspection
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 - -
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):
Depth below grade: - -
Material of construction:
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow`
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
74 Pin Oaks Dr. _
Property Address —
Ama Torence' Davies
Owner Owner's Name
information is required for every Barnstable f Ma. 02630 2-10-21
--- _ --
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):
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.):
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
�n Title 5 Official ' Inspection Form
I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
V. y 74 Pin Oaks Dr.
Property Address
Ama Torence' Davies
Owner Owner's Name
information is Barnstable Ma. 02630 2-16-21
required for every — — -- --
page. Cityrrown 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.):
*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: s r
❑ leaching pits • number'.
❑ leaching chambers number:
❑ leaching galleries number:: --
❑ leaching trenches number, length: -
El leaching fields number, dimensions: -
® overflow cesspool number: 1 --
❑ 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 16 `
Commonwealth of Massachusetts
Title 5 Official Inspection Form
`i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Pin Oaks Dr.
Property Address
Ama Torence' Davies
Owner Owner's Name
information is required for every Barnstable Ma. 02630 2-10-21
- - _ -- ---- ---
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.):
SAS is a 6x6x6 block cesspool,Pool is clean and dry with no sign of failure _
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 2
Depth —top of liquid to inlet invert t
5:
Depth of solids layer 01
Depth of scum layer 0
a
Dimensions of cesspool 6x6x6
Materials of construction Stone _
Indication of groundwater inflow ❑`Yes . ® No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Water lever at 1' clean stones all around
a
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
r
Commonwealth of Massachusetts
l? Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
74 Pin Oaks Dr.
Property Address
Ama Torence' Davies - —
Owner Owner's Name
information is Barnstable _Ma. 02630 _2-10-21 _
required for every — - - -
page. City/Town 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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
.� Commonwealth of Massachusetts
t
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments,
>r
74 Pin Oaks Dr. — -- — --- -- --- ---
Property Address
Ama Torence' Davies_ ----
Owner Owner's Name
information is Barnstable Ma. _ 02630 2-10-21
required for every - -- ——— — — State Zip Code Date of Inspection
page. City/Town
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
/ r•. ' �61fW e' ,
Ij I
4 ■ .
33
26
,
48 47
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 118
� Commonwealth of Massachusetts
.. Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form Not for Voluntary Assessments
............ 74 Pin Oaks Dr:
Property Address
Ama Torence' Davies
Owner Owner's Name
information is bl t arnsae Ma. 02630 . 2-10-21
required for every B — --
page. Cityfrown State Zip Code Date of Inspection
D. System Information (Cont.)
x
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
b ,
Estimated depth to high groundwater: 2 fe eett
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:
Back yard drops off 25'+with no sign of ground water
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
n
cam, 'Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
J� 74 Pin Oaks Dr.
v� Property Address
Ama Torence' Davies
Owner Owner's Name
information is required for every Barnstable Ma. 02630 2-10-21
-- -
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
r .
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 "
t
Qa�i�om a a0'
lip .
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
�h
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/.� 74 Pin Oak
Property Address
Al&Judy Minucci
Owner Owner's Name
information is Barnstable
required for MA 02630 August 6, 2013
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:t n llng out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not
use the return Name of Inspector
key, Septic Inspection Services Co.
Company Name
PO Box 1487
Company Address
Marstons Mills MA 02648
2a�n Cityrrown State — Zip Codei
508.428.1779 Sl 12855
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this adc.ress and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
August 6, 2013 Job# 13-73
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
15ms•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 1 of 17
r-
Commonwealth of Massachusetts
Title 5 OfficialInspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
74 Pin Oak
Property Address
Al&Judy Minucci
Owner — _......_�......_. __._—_
Owners Name
information is Barnstable
required for MA 02630 August 6, 2013
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
Cesspool and overflow were dry with no evidence of surcharge.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "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):
t5ins•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 2 of 17
r
Commonwealth of Massachusetts
Mamma Title 5 Official Inspection For
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
74 Pin Oak
Property Address
Al&Judy Minucci
Owner Owner's Name
information is Barnstable
required for MA 02630 August 6, 2013
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired,
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(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(Exp[ain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
i. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
[❑ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Tdle 5 Offiaal Inspection Form:Subsurface Sewage-Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
r Title 5 Official Inspection For
h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Pin Oak
Property Address
Al &Judy Minucci
Owner Owner's Name
information is required for Barnstable MA 02630 August 6,2013
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)anu 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.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® 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 o-available volume is less
than_day flow
t5ins-3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 4 of 17
Commonwea
lth of Massachusetts
Tide 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
74 Pin Oak
Property Address
Al&Judy Minucci
Owner Owners Name
information is Barnstable
required for MA 02630 August 6, 2013
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cost.)
Yes No
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
® Any portion of cesspool or'privy is within 100 feet of a surface water supply or
tributary to a surface water supply. -
El ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis, [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equaO to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-_
10,000gpd.
® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either"yes"or"no"to each of the follc.ving, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
0 ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone ll 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 cor.�act the appropriate
regional office of the Department.
t5ins•3113 Title 5 ofrroai Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Pin Oak
Property Address
Al&Judy Minucci
Owner Owners Name
information is Barnstable MA 02630 August 6, 2013
required for g
every page. City]Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as NIA)
® ❑ 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))
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): NIA Number of bedrooms (actual): 6
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A
t5ins-3113 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page a of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ug
� 74 Pin Oak
Property Address
Al&Judy Minucci
Owner Owners Name
information is Barnstable required for MA 02630 August 6, 2013
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? 0 Yes ❑ No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: UnknownDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? Yes [] No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-£ 74 Pin Oak
Property Address
Al&Judy Minucci
Owner Owner's Name
information is Barnstable MA 02630 August 6, 2013
required for g
every page. Cityrrown State Zip Code Date of inspection
D. System Information (cost.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Last pumped 6-7 years ago.
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the IIA system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
15ins.3113 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page s of 17
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ale 74 Pin Oak
Property Address
Al&Judy Minucci
Owner Owner's Name
information is
required for Barnstable MA 02630 August 6, 2013
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cons)
Approximate age of all components, date installed(if known)and source of information:
Unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® cast iron ❑40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: - years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins-3/13 Title 5 Official inspection form Sutsurfaoe Sewage Dispaaal System•Page 9 of 17
I
Commonwealth of Massachusetts
i Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Pin Oak
Property Address
Al&Judy Minucci
Owner Owner's Name
information is 9
required for Barnstable 'MA 02630 August 6, 2013
every page. City/Town State Zip Code Data of Inspection
D. System Information (cont.)
Septic Tank(cont.)
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
Distance from bottom of scum to bottom of outlet tee or baffle
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.):
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins-3113 Title 5 Official Inspection Farm.Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
74 Pin Oak
Property Address
Al&Judy Minucci
Owner Owner's Name 7-
requinform
r on is Barnstable MA 02630 AVgust 6, 2013
requiredd for _
every page. Citylrown State Zip Code Date of inspection
D. System Information (cons.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc,):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons — --
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: [] Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.).-
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
15ins 3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Pago 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�y. 74 Pin Oak
Property Address
Al&Judy Minucci
Owner Owner's Name
information is Barnstable MA 02630 August 6, 2013
required for g
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate.on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: [l Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances,etc.).-
If pumps or alarms are not in working order,system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
15ins-3l13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
i
Commonwealth of Massachusetts
= Title 5 Official Inspection For
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r
74 Pin Oak
Property Address
Al&Judy Minucci
Owner Owner's Name
information is required for Barnstable MA 02630 August 6 2013
_
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number.
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: One 6x6 block
pit.
❑ 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.):
Pit was empty at time of inspection, no definite stain lines.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration One w/overflow pit
Depth—top of liquid to inlet invert 5
Depth of solids layer
0"
UI
Depth of scum layer
Dimensions of cesspool 6x6
Materials of construction Stone
Indication of groundwater inflow ❑ Yes ® No
15ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17
f
Commonwealth of Massachusetts
m Tide 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Pin Oak
Property Address
A(&Judy Minucci
Owner Owner's Name
information is Barnstable MA 02630 August 6, 2013
required for g
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc_):
Cesspool was empty with no signs of surcharge.Tee to overflow pit was intact and clear.
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.):
15ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage 0isposal System Page 14 of 17
Commonwealth of(Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
.y -
\` 74 Pin Oak
Property Address
AI & Jul Minuca
Owner
Owner's Name
information is Barnstable MA 02630 Au ust 6, 2013
required for ......... ...- .. .. _. .. . ._. _. -- ---�—_._...`..__..__..
every page Citylrown �__— State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
r\
Garage
/• \ +'ram• •r\ '\/ vA' T+S�•r .•'
33
26
48 47
r
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
74 Pin Oak _
Property Address
AI &Judy Minucci
Owner Owner's Name
information is 9 required for Barnstable MA 02630 August 6, 2013
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cant.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water. 20+
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:
Low area of abutting property with no surface water is considerably lower tr an system.
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal Syslem•Page 16 of 17
I
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
- � 74 Pin Oak
Property Address
Al &Judy M:inucci
Owner Owner's Name
information is Barnstable MA 02630 August 6 2013
required for 9 ,
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary; A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
---- _ +
BEALE WAY
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140.00' 15B 33 i i 4i t
TOWN OF BARNSTABLE
LOCATION -7* t:a NI OAjg{ :IZ, SEWAGE# jam
VILLAGE JA Z. c ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY f
LEACHING FACILITY.(type) '��e,of- (size) I;A,-DLfy 61-3
NO.OF BEDROOMS - -
OWNER
PERMIT DATE: i [— i-c�A COMPLIANCE DATE: 2
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) 9 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) 4A= Feet
FURNISHED BY
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GLASS CUPOLA V/
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�— EXISTIN. CHIMNEY NEW GA11BREL ROOF
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BLACK ARLNR'EC URAL ASPHALT SMINGLES TYP.
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FRONT ELEVATION REAR ELEVATION
SCALE- 1/4' V-O° SCALE: 1/4' 1'-0'
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LEFT ELEVATION RIGHT ELEVATION ,A32 14OI
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�� DATE= 4114/14
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— LALLY COL - .`_•
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DATE 2/24/I4
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FRONT ELEVATION REAR ELEVATION
SCALE: 1/4" _ V-O" SCALE_ 1/4" I'-O"
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SCALE: 1/4" 1'-O" AS-BUILT SCALE: 1/4"
JOB: 1401
DRAM BY, KW
DATE- 4/14A4
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LEGEND SYSTEM PROFILE ALL SYSTEM COMPONENTS SHALL BE NOTES
MARKED WITH MAGNETIC TAPE OR
(NOT TO SCALE) COMPARABLE MEANS FOR FUTURE LOCATION. 1. DATUM IS NAVD 88
99- EXISTING CONTOUR SYSTEM DESIGN. "
ACCESS COVERS TO WITHIN 6" OF FIN. GRADE 2" pEASTONE OR GEOTEXTILE CONCRETE COVERS TO WITHIN 3 GRADE 2. MUNICIPAL WATER IS EXISTING
X 99.' EXIST. SPOT ELEV. TOP FOUND. EL. 50.19' FILTER FABRIC OVER STONE Barnstable Harbor
-[99]- PROPOSED CONTOUR GARBAGE DISPOSER IS NOT ALLOWED \ 41.0' MINIMUM .75' OF COVER OVER PRECAST 2X SLOPE REQUIRED OVER SYSTEM 40.0 -42.0 3. MINIMUM PIPE PITCH TO BE 1/8" PER FOOT.
WATERTEST D'BOX FOR LEVELNESS BLOCKS OR 4: DESIGN LOADING FOR ALL PROPOSED PRECAST UNITS
198 4 PRECAST H-10 MIN. 2" WALL THICKNESS PRECAST RISERS TO BE AASHO H-M o
] PROPOSED SPOT EL. DESIGN FLOW: 5 BEDROOMS ® 110 GPD = 550 GPD RISERS (TYP.)
2'® 4"OSCH40 PVC MORTAR ALL ' o
TH1 ' ` INVERT IN 38.17 oc
USE A 550 GPD DESIGN FLOW t: PIPES LEVEL 1ST 2' �ENDS
4. COMPONENTS 4, 5. PIPE JOINTS TO BE MADE WATERTIGHT.TEST HOLE i; (Np°) SIDES ° 39.0'
Y .• ...
SEPTIC TANK: 550 GPD 2 1100 1500 GAL H-10 » ' POJb�OVOva' . •::; 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH o o az
46.19' t o 14
° ° ° ° °°°°°°°°
Zip SLOPE OF GROUND 38.78 °°°° °° ( ) -
TEE SEPTIC TANK TEE 8.53 ® ® ' ° ° 310 CMR 15.000 TITLE 5. " ec
USE A 1500 GAL. SEPTIC TANK , , o , o s' MIN. SUMP - $°g°o00° ® ® ® ® a®B
_ " -0
" " " ° ° ° ® ® ®® '0.0° ° ° ° 7. THIS PLAN IS FOR PROPOSED WORK ONLY AND NOT TO
°+90'0'0�0�09 12" MIN. INT. DIM. $°o°0 ° °0°0°
GASH a ° ° ° B ° ° ° BE USED FOR LOT LINE STAKING OR ANY OTHER
UTILITY POLE LEACHING: 38.44 8.2 >°o°o °o ® ® ® ® ® ®�® ®® -'°o°o°o°o cocas o
. °° °°°0° °°°°°°°° 36.17'
:: +: 4 LIQ. LEVEL (ACME OR EQUAL)
SIDES: 2 (42.0 + 12.8) 2 (.74) = 162.2 GPD •'., '` r PURPOSE. moo.
tiY FIRE HYDRANT •'."�'• 000°000°o�o°°:010°°°°°o�°oo°°o6°o°°o'°o°o°O°o°°a°°oio'o°'o
°Q00000�°„o o�o,o°ob00000�o�o�o�o o„o°ceoao. H-10 500 GAL. LEACHING CHAMBERS BY ACME PRECAST OR EQUAL god c
NOTE: NOT ALL SYMBOLS MAY APPEAR IN DRAWING BOTTOM 42.0 x 12.8 .74 = 397.8 GPD 3/4"-1-1/2" DOUBLE WASHED STONE 4' WN. (4) UNITS REQUIRED 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4 PVC. Q
( ) ALL AROUND PRECAST STRUCTURES
1 6" CRUSHED STONE OR MECHANICAL. OVERALL DIMENSIONS TO OUTSIDE OF STONE: 42.00' X 12.83' 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED
TOTAL: 757 S.F. 560 GPD I - COMPACTION. (15.221 [2]) WITHOUT INSPECTION BY BOARD OF HEALTH AND o �O'/goo
1 � PERMISSION OBTAINED FROM BOARD OF HEALTH. a
USE 4 500 GAL. LEACHING CHAMBERS ACME OR EQUAL ( 12 x SLOPE) ( X SLOPE) (-!-X SLOPE)
THE INSTALLER SHALL VERIFY THE ( ) ( ) 10. CONTRACTOR SHALL BE RESPONSIBLE FOR CALLING
LOCATIONS OF ALL UTILITIES AND ALL WITH 4.0' STONE ALL AROUND FOUNDATION 62' SEPTIC TANK 9' D' BOX 12' LEACHING 21.5 BOTTOM TH-2 DIGSAFE (1-888-344-7233) AND VERIFYING THE LOCUS MAP
BUILDING SEWER OUTLETS AND FACILITY NO GROUNDWATER FOUND LOCATION OF ALL UNDERGROUND & OVERHEAD UTILITIES
ELEVATIONS PRIOR TO INSTALLING ANY PRIOR TO COMMENCEMENT OF WORK.
SLAB
PORTION OF SEPTIC SYSTEM 76' SCALE 1"=2000'f
11. ANY UNSUITABLE MATERIAL ENCOUNTERED SHALL BE
(9•8X SLOPE) REMOVED BENEATH AND 5' AROUND THE PROPOSED ASSESSORS MAP 279 PARCEL 91
LEACHING FACILITY.
12. EXISTING LEACHING FACILTY SHALL BE PUMPED AND LOCUS IS WITHIN FEMA FLOOD ZONE X
REMOVED OR PUMPED AND FILLED'WITH CLEAN SAND. (AREA OF MINIMAL FLOOD HAZARD) AS
SHOWN ON COMMUNITY PANEL #25001 CO554J
DATED 7/16/2014
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BENCHMARK:
BOUND DH
-37.96'NAVD88 _JJ X
E _
'A
39 "- �_X-_-•- x
X SB2'46'48"\N
x \
120.00'
X
30 OAK P�OLILLY DE 41' OF 40 MIL LINER AT 5'
TEST HOLE LOGS
PATCH FF SAS IN AREA S P AT
PATCH OM AT EL. 3 . '
i 3 ELEV. 39.0,
oX ENGINEER: DANIEL E. GONSALVES, SE #13587
5' REMOVA UNSUITABLE SOIL REQUIR cc) NS
q 1 40 �O AROUN RIMEIER OF LEA ING WITNESS: DAVE STANTON
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6 30 21
DOWN TO SUITABLE AYE . REPLACE Z
Z .0 WI CLEAN MED X AND, TO MEET m 70 DATE: / /9), ft
X I PECIFICA S OF 310 5. 55(3)
4 42a 14 PINE I r41 PERC. RATE _ < 2 MIN/INCH
T(TYP.) I 0 ��, CLASS I SOILS PIT 21 -181
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B B/
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T NE EXISTING DWELLING TOP 0, 7 S.F h UNSSOILBLE " 10YR 4/6 a 10YR 4/6
s1Ps ( 54 ' 36.2 50 36.3'
FNDN EL. = 50.19' I /
47 SNW G / C1
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2.5Y 5/3 2
�0 144" 28.7' 144" .5Y /3
5 28.5'
EXISTING
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0.0 SIEVE
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+' ^ 228" 21.7' 228" 21.5'
a O NO GROUNDWATER ENCOUNTERED
TITLE 5 ' SITE PLAN
50 OF
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WEST BARNSTABLE
PREPARED FOR
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AMA , TORRANCE
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DATE: SEPT. 7, 2021
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Scale: 1"= 20'
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11
0 10 20 30 40 50 FEET
DAN
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D =1 q No.40960 , Ivo. d�'3502 �
Off 508-362-4541
Nal E�G.�'=�_' fax 508 362-9880
O _qN0 SURVE ---- L�� ( downcope.com
o down cape engineering, inc.
o Q civil engineers
Ian d surveyors
Dl� 939 Main Street ( Rte 5A)
YARMOU THPOR T MA 02575
DCE #2 >-222 � DATE DANIEL A. OJAI�A, P.E., P.L.S.
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� 21-222 TORRANCE.DWG
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