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LOCATION e9 I`1 SEWAGE#�^S
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NO.OF BEDROOMS
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Y PERMIT DATE: C®1t+B' E DATE:n5P 3 /a&1o8
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �1
V 274 Arrowhead Drive, Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives
Owner Owner's Name
information is required for Hyannis MA 02601 March 26, 2008
every page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms.may not be altered in any
way.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co.
Company Name
189 Cammett Road
Company Address
Marstons Mills MA t 02648 ,
' City/Town State j Zip Code; ;
508-428-1779 t '4j
Telephone Number License Number -
s'
B. Certification ;]
t�
I certify that I have personally inspected the sewage disposal system at this address and that the
n information reported below is true, accurate and complete as of the time of the inspection. The'inspeetion
was performed based on my training and experience in the proper function and maintepance 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:
o
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
March 26, 2008
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.
08-69 Freddie Mac.doc•08/D6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
274 Arrowhead Drive, Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives
Owner Owner's Name
information is required for Hyannis MA 02601 March 26, 2008
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:
® 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:
Infiltrators have no evidence of surcharge, tank is not in need of pumping at this time.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for 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.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
0&69 Freddie Mac.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
274 Arrowhead Drive, Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives
Owner Owner's Name
information is required for Hyannis MA 02601 March 26, 2008
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
08-69 Freddie Mac.doc•0a106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
274 Arrowhead Drive Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives
Owner Owner's Name
information is required for Hyannis MA 02601 March 26, 2008
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria 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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than_day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
08-69 Freddie Mac.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 or 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
274 Arrowhead Drive, Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives
Owner Owner's Name
information is required for Hyannis MA 02601 March 26, 2008
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the 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 following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section Ethe system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
08-69 Freddie Mac.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
274 Arrowhead Drive, Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives
Owner Owner's Name
information is required for Hyannis MA 02601 March 26, 2008
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 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)]
08-69 Freddie Mac.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
274 Arrowhead Drive, Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives
Owner Owner's Name
information is required for Hyannis MA 02601 March 26, 2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
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
Number of current residents:
0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
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:
Last date of occupancy/use: Date
Other(describe):
08-69 Freddie Mac.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
274 Arrowhead Drive, Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives
Owner Owner's Name
information is required for Hyannis MA 02601 March 26, 2008
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
None
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)
❑T Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
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
08-69 Freddie Mac.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
274 Arrowhead Drive Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives
Owner Owner's Name
information is Hyannis MA 02601 March 26, 2008
required for y
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 1
p g 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: 1
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: 10.5' long x 5.8'wide- 1500 gal.
3"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
30"
2"
Scum thickness
61'
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
12"
Measured
How were dimensions determined?
08-69 Freddie Mac.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
274 Arrowhead Drive, Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives
Owner Owner's Name
information is required for Hyannis MA 02601 March 26, 2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tees are intact and clear, liquid level was found at bottom of outlet invert.
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.):
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):
08-69 Freddie Mac.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
274 Arrowhead Drive, Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives
Owner Owner's Name
information is required for Hyannis MA 02601 March 26, 2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
011 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.):
No solids or high stains present, liquid level was found at bottom of outlet pipe.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
08-69 Freddie Mac.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 111 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
274 Arrowhead Drive, Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp C/O Tim Waldron Realty Executives
Owner Owner's Name
information is Hyannis MA 02601 March 26, 2008
required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® Infiltrators
leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
I
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No standing water or evidence of surcharge in Infiltrators.
08-69 Freddie Mac.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
274 Arrowhead Drive, Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives
Owner Owner's Name
information is required for Hyannis MA 02601 March 26, 2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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.):
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.):
08,69 Freddie Mac.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
274 Arrowhead Drive, Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives
Owner Owner's Name
information is required for Hyannis MA 02601 March 26, 2008
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
Arrowhead Drive
Water
Service
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Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
274 Arrowhead Drive, Hyannis MA 02601
Property Address
Federal Home Loan Mortgage Corp. C/O Tim Waldron Realty Executives
Owner Owner's Name
information is Hyannis MA 02601 March 26, 2008
required for y
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers - (attach documentation)
® Accessed USGS database-explain:
USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water at el 25 and topo map shows property at el. 50.
08-69 Freddie Mac.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
OF THE Town of Barnstable
. T�
Regulatory Services
,LA"S,,,B Thomas F. Geiler,Director
9`b "iB39 Public Health .Division
p�ED MA'S A
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts,.Department of;Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division:does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In.addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
i
TOWN OF BARNSTABLE
LOCATION rP11%-t SEWAGE #
VILLAGE �� n ►S tM ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. 0.6I f �C -i 1`C-
Z�ti J
SEPTIC TANK CAPACITY E I I l
LEACHING FACILITY: (type) (size)
FCC
LNO.OF BEDROOMS
1!BUILDER OR OWNER `
PERMTTDATE�ce
COMPLIANCE DATE.`
I
Separation Dist
Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist'
on site or within 200 feet of leaching facility) Feet
Edge-of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
I rm m u A"I w um M. eaten the bulldl- •�'
bm .dvnmt Wane en Aic water s�PPIY
rw
2-3,
a�G
to
3
TOWN OF BARNSTABLE �-L
LOCATION 7 RO��!46•D_ DR: SEWAGE # : :50�,
-VILLAGE �a ASSESSOR'S MAP & LOT
t INSTALLER'S NAM_E & PHONE NO. A & B CANCO 775-6264
'`•.SEPTIC TANK CAPACITY C�C�
LEACHING FACILITY:(type), 114 4X VA Q��ti� (size) 30'K 1 ��X Z�
,t x
'Nb OF BEDROOMS' PRIVATE WELL OR PUBLIC WATER
7¢BUILDER OR OWNER
,DATB PER41T ISSUED:'. �5:
DATE COMPLIANCE ISSUED: Ti'- la—9'4t
VARIANCE GRANTED: Yes No
_�
ss �
,�
_ �
��iit•,
:. , _.___
_.�
^ i
11 � oeT � � .. _ i_� i,
i �` .. 6 �''.. . . � l-: t.
•�
ii ---4k
No. _r v — O Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
0[pplication for Migpogal &pgtem Congtruction Permit
Application for a Permit to Construct( )Repair(.Upgrade( )Abandon( ) O Complete System ❑Individual Components
t
Location Address or Lot No. 7Y �/Dk)hC&Cf 0r, Owner's ppme,Ad ress d Tel.No.
Assessor's Map/Parcel a �Q /U q a
` s 79o-a5,70
Installer's Name,Address,anK,&1b CANCO Designer's Name,Address and Tel.No.
350 Mj in Street "VIA
W.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 33C) gallons per day. Calculated daily flow gallons.
" Plan Date Number of sheets Revision Date
Title
Size of Septic Tank /SO7J n nType of S.A.S. /hst t'%�%2 C r"
Description of Soil 1554n Q
Nature of Repairs or Alterations(Answer when applicable) l-,17 /,a/ ,Q/. 6. -40;'nJ1<
Date last inspected:
Agreement: r f4
+ 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 Certifi-
cate of Compliance has been issued by this Boar of alth.
Signed !, Cam_. _ Date
Application Approved by '� Date
Application Disapproved for th ollo tng reasons
Permit No. ® Date Issued -
———————————--——
No. CO -_b o c? ✓! Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 1/
Iv� IC( PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS Yes
0(ppfication for Migpool *pgtem Con.5truction Vermi't
Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. G/a W C G Owner's ame,Ad ress 9nd Tel.No.
VA I
Assessor's Map/Parcel D- )>/ D i j-, SA 9 v o�J 7 Cj
Installer's Name,Address,and Tel . Designer's Name,Address and Tel.No.
350 Main Street
-- - W. Yarmouth, MA 02673 AIIA
Type of Building:
`Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow >3U gallons per day. Calculaied'jdaily flow gallons.
Plan Date Number of sheets Revision Date
f Title ' -1
Size of Septic Tank Type of S.A.S. ;2C!—" '
Description of Soil
� I
4 n,s/A /( �- /tea u s,
N ture of Repairs or Altera ions(Answer when applicable)
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 and not to place the system in operation until a Certifi-
cate of.Compliance has been issued by this Bo af of alth.
Signed Date
Application Approved by Date 5'-(Y-
a Application Disappioved for the following reasons
_ w
Permit No,
3 1 Date Issued
———————————————————————--
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
f THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( --l"U'pgraded( )
Abandoned( )b.�� L a
i
at a?Y has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. - O W dated
Installer Designer
The issuance of this p_ermit shall nQ�tbe construed as a guarantee that the system wi 71oon as designed.
Date Inspector IV
— �/———— ———————.——————————————————— —
No. `b - 0� Fee S
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION'- BARNSTABLES MASSACHUSETTS
,T
lwizpozai *potbn Congtruction Vertu
Permission is hereby granted to Construct( )Repair Upgfade( )Ab on( )
System located at
r
and,as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
omply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: J Approved by
I
I
10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated s• / , concerning the
property located at o;��(( meets all of the
following criteria:
There are no wetlands located within 100 feet of the proposed leaching facility
'� • There are no private wells within 150 feet of the proposed septic system
/ There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the.
proposed leaching facility will 114.t be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) 5 c.,'
B)Observed Groundwater Table Elevation(according to Health Division well map) 3 oZ
SIGNED: DATE:
LICENSED SEPTIC.SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
'l7"
-�
.. ,.
_� -
<"ICr Al
SEPTIC -SY-STEM DEX.
�_ IXW .
. L BZDAWMS AT .� G AL/DAY/BKI�R00�[ _ cAL/DAY
SEPTIC TANK:
, . GAL/DAY x 2 DAYS = GAL
USE /fi d GALLON SKPT IC TANK
LBACHING AREA.-
USE S I NFI LT RAT ORS .MAXIMIZER CHAMBERS
WITH 4' Op STONE ALL AROUND If x Z DEEP)
slD.9 ARC (30 + 1112 x 2 1- -
. 'D �lR `A: W x If _ SP (74) _ GAL/DAY
GAL/DAY
cAPAcJTY
�S1�200�
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS j
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM j
PART A
CERTIFICATION '�iAP
PARCEL O L
Property Address: 274 Arrowhead Drive,Hyannis,MA LOT
Owner's Name:Valdir Delima
Owner's Address:274 Arrowhead Drive,HyannisMA
Date of Inspection: 4/28/2004 RECEIVED
Name of Inspector: REED C.ELLIS
Company Name: ELLIS BROTHERS CONST.CO. APR 2 7 2004
Mailing Address: 23 ENTERPRISE ROAD,
P.O.BOX 59,YARMOUTH PORT,MA 02675 TOWN OF BARNSTABLE
Telephone Number: 508-362-6237 HEALTH DEFT.
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved-system inspector pursuantZasses
tin 15340 of Title 5(310 CMR 15.000). The system:
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: �L2 L 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 274 Arrowhead Drive,Hyannis,MA
Owner.Valdir Delima
Date of Inspection:4=2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Pstem Passes: y�
0 I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in th "Conditional Pass»section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the fir the following statements.If`not determined"please
explain. .
The septic tank is metal and over 20 years old*or d ke septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or t mk failure is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as aj proved by the Board of Health.
*A metal septic tank will pass inspection if it is structural) sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is availabl .
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven dis ribution box.System will pass inspection if(with
approval of Board of Health):
broken pipe(s)are rep laced
obstruction is remov
distribution box is lev led or replaced
i
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are reph ced
obstruction is removed
ND explain:
2
I
I
Page 3 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:274 Arrowhead Drive,Hyannis,MA
Owner:Valdir Delima /
Date of Inspection:4t=004 /A/�
C. Further Evaluation is Required by the Board of Hear
Conditions exist which require further evaluation by he Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determin in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning,in a manner which will rotect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface ater
_ Cesspool or privy is within 50 feet of a bord vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and I ablie.Water Supplier,if any)determines that the
system is functioning in a manner that protects the pt blic health,safety and environment:
_ The system has a septic tank and soil absorpti system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface waters pply.
_ The system has a septic tank and SAS and theE kS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the S is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the S is less than 100 feet but 50 fat or more from a•
private water supply well".Method used to Merin ne distance
"This system passes if the well water analysis, rmed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates tb at the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrog is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis t iust be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:274 Arrowhead Drive,Hyannis,MA
Owner.Valdir Delima
Date of Inspection:4/28/2004
D. System Failure Criteria applicable to all systems:
You must' 'cate`yes"or"no"to each of the following for all inspections:
Yes N
Backup of sewage into facility-or system component due to overloaded or clogged SAS or cesspool
ischarge 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
_ c9spool
squid depth in cesspool is less than 6"below invert or available volume is less than%2 day flow
uired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
o times pumped
y portion of the SAS,cesspool or privy is below high ground water elevation.
y portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
fA
er supply.
_ o -on ofa cesspool or privy is within a Zone 1 of a public well.
portion of a cesspool or privy is within 50 feet of a private water supply well.
portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well Is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
l/ are triggered.A copy of the analysis must be attached to this form.]
/1l (Yes/No)The system Bile.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 t correct the failure.
E. L e Systems: r
To be considered a large system the system mus serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either`eyes"or"no"to each of a following:
(The following criteria apply to large systems in 'lion to the criteria above)
yes no
the system is within 400 feet of a surface hinking water supply
the system is within 200 feet of a tributar,,to a surface drinking water supply
r
the system is located in a nitrogen sensiti a area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone I1 of a public water supply well
If you have answered"yes"to any question in Secti n E the system is considered a significant threat,or answered
`yes"in Section D above the large system has fail .The owner or operator of any large system considered a
significant threat under Section E or failed under S ion D shall upgrade the system in accordance with 310 CMR
15.304.The system owner should contact the appr iate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:274 Arrowhead Drive,Hyannis,,MA
Owner:Valdir Delima
Date of Inspection:4/28/2004
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes N
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,x luding the SAS, located on site?
_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
oft a bathes 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:
Y no
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
1 is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 274 Arrowhead Drive,Hyannis,MA
Owner:Valdir Delima
Date of Inspection:4/28/2004
FLOW CONDITIONS
RESIDENTIAL 2
Number of bedrooms(design):—,3— Number of bedrooms(actual): c! 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):3�
Number of current residents: Z,—
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(ye or no)/-7C.Iif yes separate inspection required).
Laundry system inspected(yes or no): -�
Seasonal use:(yes or no): a"-
Water meter readings,if available(last 2 years usage(gpd#,;2�—`6(/_2w�
Sump pump(yes or no): D
Last date of occupancy:
COMMERCIAIJINDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease hap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes r no):—
Water meter readings,if available:
Last date of occupancy/use-
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: l/�/�' 094141
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:,_gallops—How was quartei ,- ed cjetermined? Y / ij,(/GIL�
Reason for pumping: S �� �' y �A)
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)
_InnovativelAlternative technology.Attach a copy of the current operation and maintenance contract(to be ti
obtained from system owner) . .
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approxima a e f,0 components,date' lled(' wn and source of information:
l�o� ��/ j
Were sewage odors detected when arriving at the site(yes or no):�!0
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 274 Arrowhead Drive,Hyannis,MA 02601
Owner:Valdir Delima
Date of Inspection:4/28/2004
BUII.DING SEWER(locate on site plan) �
A '
Depth below grade:
Materials of construction:Y cast iron /40PVC_other expl�;
Distance from private water supply well or suction line: D ti
Comments(on condition of joints,venting,evidence of l e,etc.): l '
i / Al T ti J A ble-4I l!✓�/1aGL-
SEPTIC TANK: ocate on site plan)
Depth below grade: N ���� v✓� 3�
Material of construction: �/concrete metal_fiberglass_polyethylene
other(explain)
/1/ tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):T(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from to o scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outl t tee or baffle:_0
How were dimensions determined: fit-- v y,
Comments(on pumping recommendations,inlet and outlet tee or affle con tion,sfuctural integrity,liquid levels
as r t invert, id evid nceka
�i �
GREASE TRAP:_(locate on site plan)
Depth below grade:—
Material of construction:_concrete_metal fiberglass_polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or b Lffle:
Distance from bottom of scum to bottom of outlet ee or baffle:
Date of last pumping:
,. Comments(on pumping recommendations,inlet ai d outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc,):
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 274 Arrowhead Drive,Hyannis,MA
Owner:Valdir Delima
Date of Inspection:4/28/2004 Ape
TIGHT or HOLDING TANK: (tank must be of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:�Oif 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 5pox etc.):
fl o 7
.1/�
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:274 Arrowhead Drive,Hyannis,MA
Owner:Valdir Delima
Date of Inspection:4/28/2004
SOIL ABSORPTION SYSTEM(SAS)-" (locate on site plan,excavation not required)
If SAS not located explain why:
Tyler jz64-40
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
1 ching trenches,number,length: e
7�L1ching fields,number,dimensions: �D
overflow cesspool,number: ,
innovativelalternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic fail ,level ofponding,damp soil,condition of vegetation,
etc. : � .r
CESSPOOLS: (cesspool must be pumped as part�inspectionXlocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic fail ,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) W
Property Address:274 Arrowhead Drive,Hyannis,MA S N
Owner:Valdir Delima
Date of Inspection:4/28/2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all we Is within 100 feet.Locate where public water supply enters the building.
0
J
. 2 Z3
f�' Y 3 D
32 6
04
10
3
Page 11 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 274 Arrowhead Drive,Hyannis,MA
Owner:Valdir Delima
Date of Inspection:4/28/2004
SITE EXAM
Slope
Surface water
Check cellar (�
Shallow wells n7 A/ t4
Estimated depth to ground water off$ feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on.record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
,Checked with local excavators,installers-(attach ocume i n)
Accessed USGS database-explain: C�c '� NQ
You must describe how you established the high ground water elevation:
_oat I
•G�" !/ V
v