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Commonwealth of Massachusetts
Title 5 Official Inspection Fora,
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v 247 Bearses Way, Hyannis M - 310 P -.3 '
Property Address n.J
Antonio Dias
Owner Owner's Name
y'.
information is 247 Bearses Way, Hyannis MA 02601 June 16, 2020
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 A. Inspector Information / - rr
filling out forms J 9
on the computer,
use only the tab Troy Williams
key to move your Name of Inspector
cursor-do not Troy Williams Septic Inspections
use the return Company Name
key.
Hummel Drive
r� Company Address
South Dennis MA 02660
Cityrrown State Zip Code
(508) 385 - 1300 S1682
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
June 16, 2020
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
<lo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
247 Bearses Way, Hyannis M - 310 P -3
Property Address
Antonio Dias
Owner Owner's Name
information is
required for every y 247 Bearses Way, Hyannis MA 02601 June 16, 2020
page. Cityrrown 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 meets minimum standards set by Massachusetts DEP at the time of inspection only.This
inspection is not a guarantee or warranty on the future working conditions of leaching, pipes,
components or the future structural integrity of said components and only represents conditions found
at the time of inspection only.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
247 Bearses Way, Hyannis M -310 P -'3
Property Address
Antonio Dias
Owner Owner's Name
information is required for every 247 Bearses Way, Hyannis MA 02601 June 16, 2020
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc rev.7/26/2018 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
247 Bearses Way, Hyannis M -310 P -3
Property Address
Antonio Dias
Owner Owner's Name
information is required for every 247 Bearses Way, Hyannis . MA 02601 June 16, 2020
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to,this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following'for all inspections:
Yes No
❑ ® 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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
247 Bearses Way, Hyannis M -310 P -3
Property Address
Antonio Dias
Owner Owner's Name
information is required for every 247 Bearses Way, y Hyannis MA 02601 June 16, 2020
page. Cityrrown 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 '/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.
❑ ® Any portion of cesspool or privy is within 100.feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of 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.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
247 Bearses Way, Hyannis M - 310 P -3
Property Address
Antonio Dias
Owner Owner's Name
information is required for every 247 Bearses Way, Hyannis MA 02601 June 16, 2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
® ❑ 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?
I
® ❑ 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
to Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
247 Bearses Way, Hyannis M -310 P -3
Property Address
Antonio Dias
Owner Owner's Name
information is required for every 247 Bearses Way, Hyannis MA 02601 June 16, 2020
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to: N/A
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 19=38,000 gals.
g ( y g (gpd)): 18=42,000 gals.
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
t5insp.doc•rev:7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
u 247 Bearses Way, Hyannis M - 310 P -3
Property Address
Antonio Dias
Owner Owner's Name
information is required for every 247 Bearses Way, Hyannis MA 02601 June 16, 2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
Design flow(based on 310 CMR 15.203): N/AGallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: N/A
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: N/A
Last date of occupancy/use: N/A
Date
Other(describe below):
N/A
I
3. Pumping Records:
Source of information: No pumping info available.
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
�a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
247 Bearses Way, Hyannis M -310 P -3
Property Address
Antonio Dias
Owner Owner's Name
information is y
required for every , y 247 Bearses Wa Hyannis MA 02601 June 16, 2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ 1 Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
D-box and leaching were installed to existing tank from 1998 on 12/15/14 per compliance.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 18"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.):
Lines were found clear at the time of inspection.
i
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
_ r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
247 Bearses Way, Hyannis M -310 P -3
u Property Address
Antonio Dias
Owner Owner's Name
information is
required for every y 247 Bearses Way, Hyannis MA 02601 June 16, 2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'
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: 6'X10.5'X6' 1500 gallon
Sludge depth:
4"
2, $"
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness none
Distance from top of scum to top of outlet tee or baffle
6"
' Distance from bottom of scum to bottom of outlet tee or baffle 16"
i
How were dimensions determined? probe/measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pvc outlet tee was found present and in working order. No inlet tee present. No evidence of leakage
or damage was found. Tank was not in.need of pumping at this time.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
�9 Title 5 Official* Inspection Form
< Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
247 Bearses Way, Hyannis M - 310 P -3
Property Address
Antonio Dias
Owner Owner's Name
information is y
required for every � y 247 Bearses Way, Hyannis MA 02601 June 16, 2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: N/Afeet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions: N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/A
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.):
N/A
8.• Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
N/A
Capacity: N/A
gallons
Design Flow: N/Agallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
247 Bearses Way, Hyannis M -310 P -3
Property Address
Antonio Dias
Owner Owner's Name
information is required for every 247 Bearses Way, Hyannis MA 02601 June 16, 2020
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order: ❑ Yes ❑ No
Date of last pumping: N/ADate
Comments (condition of alarm and float switches, etc.):
N/A
*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 level
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box was found level and in working order. No evidence of solid carry-over or backup in the past
was found at the time of inspection.
i
i
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 112 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
247 Bearses Way, Hyannis M -310 P -3
Property Address
Antonio Dias
Owner Owner's Name
information is
required for every 247 Bearses Way, Hyannis MA 02601 June 16, 2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No`
Comments(note condition of pump chamber, condition of pumps and.appurtenances, etc.):
N/A
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2 -500 gallonwith 4' stone
❑ leaching galleries number: 25'X 12.8'X 2'
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system t
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
it
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
247 Bearses Way, Hyannis M -310 P-3
Property Address
Antonio Dias
Owner Owner's Name
information is y� y required for every 247 Bearses Wa Hyannis MA 02601 June 16, 2020
page. Cityrrown 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.):
Soil was sandy. Chambers had a low water level present at the time of inspection. Checked stone
and found dry and clean. No evidence of hydraulic failure or problems in the past were found at the
time of inspection.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert N/A
N/A
Depth of solids layer
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
247 Bearses Way, Hyannis M -310 P -3
Property Address
Antonio Dias
Owner Owner's Name
information is Wa 247 Bearses
required for every y, Hyannis MA 02601 June 16, 2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: N/A
Dimensions N/A
Depth of solids N/A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
t
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 247 Bearses Way, Hyannis M -310 P-3
Property Address
Antonio Dias
Owner Owner's Name
information is 247 Bearses Way, Hyannis MA 02601 June 16, 2020
required for every —
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
�e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
247 Bearses Way, Hyannis M -310 P -3
Property Address
Antonio Dias
Owner Owner's Name
information is y� y
required for every 247 Bearses Wa Hyannis MA 02601 June 16, 2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) '
15. Site Exam: ,
® Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
10.04
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed:" Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:.
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
AIW 230 Zone D 19.8' .0' adjustment
You must describe how you established the high ground water elevation:
Hand augered 3' below bottom of leaching with no water found at a depth of 10.0'. Groundwater
adjustment at the time of inspection was .0'. Bottom of leaching at 7.0'was found not to be located in
the high groundwater elevation at the time of inspection.
I
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
247 Bearses Way, Hyannis M -310 P -3
Property Address
Antonio Dias
Owner Owner's Name
information is 247 Bearses Way, Hyannis MA 02601 June 16, 2020
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
I�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
c�
247 Bearses Way
Property Address w
Mecrones1-5
Owner Owner's Name 1 5
information is
required for every Hyannis Ma T.
N
page. Cityrrown 10/23/17 ,
State Zip Code Date of Inspection '
• r/1
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.
'mngout forms A. General Information
filling out forms
on the computer,use only the tab 1 Inspector:
key to move your
cursor-do not Chad Hathaway
use the return
key. Name of Inspector
H.P.S.
-1W11 Company Name
P.O.Box 151
Company Address
Forestdale Ma
Cityrrown 02644
State Zip Code
774-274-2581 12866
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system Inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/23/17
Inspector's Signatu 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.
t5ins•3/13
Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Lo 9)td
Commonwealth of Massachusetts
Title 5 Official Inspection
U
p on Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
247 Bearses Way
Property Address
Mecrones
Owner owner's Name
information is
required for every Hyannis
page. City/Town Ma 10/23/17State ZipCode
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:
Septic functioning as designed.
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
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
247 Bearses Way
Property Address
Mecrones
Owner information is Owner's Name
required for every Hyannis
Ma 10/23/17
page. CltylTown State Zi Code
Date of Inspection
P
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(cunt.):
❑ 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 pipes)are replaced ❑ Y ❑ N
. ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N
. ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N
❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
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•3/13
Title 5 MOW Inspection Form:Subsurfaos Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
247 Bearses Way
Property Address
Mecrones
Owner Owner's Name
information is
required for every Hyannis
Cityrrown Ma 10/23/17
page. 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)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*'This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
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
E] ® 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
t5ins•3113
Title 5 Official hspeeUon Forth.Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
247 Bearses Way
Property Address
Mecrones
Owner Name
information is owner's
required for every Hyannis
page. Cd Ma 10/23/17y/Town State ZipCode
Date of Inspection
B. Certification (cont.)
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.
❑ ® 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 E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113
Title 5 Official Inspection Forth:Subsurface Sewa$e Disposal system.Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o rm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
247 Bearses Way
Property Address
Mecrones
Owner s Name
information is Owner'
required for every Hyannis Ma
page. CltylI own 10/23/17
C. Ch State Zip Code Date of Inspection
ecklist
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?
I
® ❑ 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)1
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
t5ins-3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
247 Bearses Way
Property Address
Mecrones
inform
Owneration is Owner's Name
required for every �annis Ma
page. Cltyrrown 10/23/17
State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3-4
Does residence have a garbage grinder?
❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected?
® Yes ❑ No
Seasonal use?
❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump?
❑ Yes ® No
Last date of occupancy: current
Date
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?
i ❑ 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-P89e 7 or 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
247 Bearses Way
Property Address
Mecrones
Owner Owners Name
information is
required for every Hyannis
C"I I own Ma 10/23/17
page. State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
General Information
Pumping Records:
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:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool ,
0 Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) i
❑ 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):
t5ins•3/13
TiBe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official- Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
lug247 Bearses Way
Property Address
Mecrones
Owner 's
information is Owner Name
required for every Hyannis
Cityfrown Ma 10/23/17
page. State Zip Code Date of Inspection ,
D. System Information (cont.)
Approximate age of all components, date installed(if known)and source of information:
tank on anal to house leaching and Dbox 2014
Were sewage odors detected when arriving at the site?
❑ .Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5'
feet
Material of construction:
❑cast iron ®40 PVC
❑other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments(on condition of joints,•venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):-
Depth below grade: , 1'
. 1 feet
Material'of construction:
®concrete El 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 t
❑ No
Dimensions: 1000 gallon
Sludge depth: 3"
t5ins•3/13
Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
rt 247 Bearses Wa
Property Address
Mecrones
Owner Owner's Name
information is .
required for every Hyannis Ma
page. Cityrrown 10/23/17
State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle 31"
Scum thickness 1"
Distance from top of scum to top of outlet tee or baffle 5"
Distance from bottom of scum to bottom of outlet tee or baffle 18
How were dimensions determined? tape and sludge judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
pump every 2-3 years as maint. to protect leaching Tees in place no visable cracks or leaks to tank
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑concrete ❑ metal ❑fiberglass g ❑ 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
Tole 5 Official Inspection Form: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
247 Bearses Way
Property Address
Mecrones
Owner Name
information is Owner's
required for every Hyannis 10/23/17
Ma
page. CttylTown State Zip Code Date of Inspection
mation
D. System Infor (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.):
0.
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 9 ❑ 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
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
a 247 Bearses Way
Property Address
Mecrones
Owner owners Name
information is
required for every Hyannis
Ma 10/23/17
page. City/Town 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 0
.Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Dbox in good condition no carry overs no concrete cracks or decay. Liquid level at bottom of outlet
pipe. Camera Inspected. Dbox new in 2014
Pump Chamber(locate on site plan):
Pumps in working order:
❑ Yes ❑ No*
Alarms in working order: El 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:
t5ins-3113
Title 5 Official Inspection Fomr.Subsurkm Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
247 Bearses Way
Property Address
Mecrones
Owner information is Owner's Name
required for every Hyannis Ma 10/23/17
page. CItyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number.
® leaching chambers number: 2 500 gal. L.0
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields
number, dimensions: _
❑ . overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sewer Camera inspected Leaching chambers dry, no high staining
i
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depths—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
' Dimensions of cesspool
Materials of construction
i
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
247 Bearseslug
Wa
Property Address
Mecrones
Owner Owner's Name
information is
required for every Hyannis Ma 10/23/17
page. City/Town State Zi Code
P Date of Inspection
D. System Information (cont.)
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.): j
i
t5ins-3113
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
247 Bearses Wa
Property Address
Mecrones
Owner Owner's Name
information is
required for every Hyannis Ma 10/23/17 page. Cltyfrown State ZipCode
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
o3
�Lk
a pGcl
c U"
0-3
a'
F�3
t5ins•3/13
Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
247 Bearses Way
Property Address
Mecrones
Owner Owner's Name
information is
required for every Hyannis Ma 10/23/17
page. Cltyrrown State ZipCode
Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope ;
® Surface water
i
® Check cellar
® Shallow wells `
Estimated depth to high ground water: 17'+
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:
GIS
You must describe how you established the high ground water elevation:
town GIS map'lot is at el. 40 low in area el.23'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
247 Bearses Way
Property Address
Mecrones
Owner s Name
information is Owner
required for every Hyannis Ma 10/23/17
page. Ctty/Town State ZipCode
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•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
No. /L{ ;
Fee /O_c
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OFF BARNSTABLE, MASSACHUSETTS Yes
.;.'
ftPYication for Misposar 6pstem Construction permit
Application for a Permit to Construct(441 Repair(grade Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.,2 Y I Owner's N)me,Address,and Tel.No.
fjy�hni5 rrl�GRarICS
Assessor's Map/Parcel 3/6-3
Installer's Name,Address,and Tel.No.f0$-Y2B-q'I 3 S Designer's Naµie,Address,and Tel.No.Yes-36 a-3u
�oseloh D� Qa<^s^os �,sy�Es' sowsrNc
7i G , 2S 7
Type of Building: J d At
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) pRC9_Q gpd Design flow provided �3c3O gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 1'4,9roll
Date last inspected:
Agreement:.
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Sign r- Date
Application Approved by Date f -�
Application Disapproved by Date
for the following reasons
Permit No.* !q 6 Date Issued c�
3
a No.: /�/ Fee
THE COMMONWEALTH�OF'•.MASSACHUSETTS Entered in computer:
:+ Yes
PUBLIC HEALTH DIVISION - TOWNIO1BARNSTABLE, MASSACHUSETTS
application for`Disposai ipsfem Construction Permit
Application for a Permit to Construct(/X Repair(grade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. S 6410 y Owner's Name,Address,and Tel.No.
Hy�grl:y �EcRvr1�5 , ..
Assessor's'Map/Parcel 510-3
Installer's Name,Address,and Tel.No.S06 -5'2G- 97 3 Z Designer's Name,Address,and Tel.No._5 o2'
JJ,5 e19h /9-, 6,Wvr6,5 S0,4•5•r1"C
/2c� l�IavSroHS /. S�a��ivrGLi v 2S 7
Type of Building: SD
r
Dwelling No.of Bedrooms/_'X/5T el/ 2 Lot Size sq.ft. Garbage Grinder( )
' Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures Design Flow(min.required) p� gpd Design flow provided , 7?
0 gpd
":. Plan Date Number of sheets Revision Date
Title- /
Size of Septic Tank Type of S.A.S.•
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
• Signe Date
Application Approved by Date f�
Application Disapproved by Date
for the following reasons
Permit No. �L� (9 Date Issued a 8-
�r THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS ._
r
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( L) Repaired Upgraded( )
Abandoned( )by 195!{,L
at has been constructed in accordance
with the provisions of Title 5 and th for Disposal/
System Construction Permit Ne�/y �/E dated
Installer,/05>rz oe ��!?lirUS Designer
#bedrooms /:xis t/i/r/ Approved design flow gpd
The issuance of this t 1 of be onstrued as a guarantee that the system w' 1 ct�Vd7eigne .
Date Inspector
, � v
------------------------------------------------------------ ------------ ----
No.c�o/ L/ I Fee
` THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal *pstem Construction permit
Permission is hereby granted to Construct(L)- Repair( 4)_ Upgrade( ) Abandon( )
System located at 7 �'Z
ff�ss9rre�i 5
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions. _
Provided:Construction must be omple/ted within three years of the date of this p rmit.
Date 49 �// �J Approved b _
12/24/2014 11: 33AM 17744139468 MEYER AND SONS PAGE 01/01
Town of Barnstable
Regulatory Services
e Richard V.Scan,Interim Director
,Am Public Health DiAsion
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form 2
Date: l� Sewage Permit# y�Assessor's MaOarcel :J v l)p 3
Designer: ey e y— Yl Installer: jam.
Qb Address: Address: 4n' 4 1� �
�! moo' as issued a permit to install a
( ate installer)
septic system at � S \'J based on a design drawn by
(address) _
S Vt-l� dated L
XI certify tha7thl� c system referenced above was installed substantially according to
the design, which tuay include minor approved changes such as lateral relocation of the
distributiort 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 ma'or changes (i.e.
greatcr 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. Plan revision or
certified as-built by designer to follow. Strip out(if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was constructed.iig compliat' a with the terms
of the 1\A approval letters (if applicable)
OF
( taller's Signature)
esigner's Signature) NI ikR►��'
PLEASE RETURN XQ a T LE PUBLIC HEALTH DIVISION `CERTIFICATE
OF CO LIANCE MRL NPJBE ISSUED UNTIL BOTH THIS yORM AND S_
BUILT CARD ARE RECEIVED By TLjLJjAMSjAnE PUBLI—C BEALTH WEVISION
THANK'YOU.
QASeptie0esigner Cerd,fication Form Rev 8-14-13.doc
�,4
Town of Ba"Mstable. P# U
Department of Regulatory Services
m : Public health Division Date
,639 tee$ 2t10 Main Street;Hy#nnis MA 02601
Date Scheduled &141, ' Time ! I�ee Pd. NO
i
i
Soil Suitabality Assessment,for Se i os
Performed By: i9AJWitnessed By:
i
- LOCATION & GENERAL INFORMATION
Location Address'. a�`� ER�-S�/ w Q Owner's Name M tG( N
1^ ^ A I Address A L-0 f Q l2-� NAA
Assessor's Map/P4rcel: 310 / 00 3 \ I Engineer's Name Keys{L #, S0-ri S , ® -�t,)
NEWCONSIRU�'CION REPAIR Telephone# b 3G(D — -13 1
Land Use CMEWZL i'L- Slopes(%) ! t7 — �� Surface Stones
2-00Wet' ?� ft Drinking Water Well
Distances from: Open Water Body ft Possible Area�_ g
Drainage Way t d ft Property Linc ft Other ft
SKETCH:(Street name,dimensions'of lot.exact locations of test holes&perc tests,locate wetlands in proxintity to holes)
. I .
Na z
7'A
I .
0-
I
Parent material(geologic) 0 LOLLCL'� I Depth to Bedrock B
Depth to Groundwaker. Standing Water in Hole:' G� i Weeping from Pit Face
Estimated Seasonal,l"ligh Groundwater
DtTERM NATION FOR SEASONAL ffiC][I WATER TALE
Method Used: in,
Depth Clbperved standing in obs.hole: In. Depth 10 Soil mottles: 1t-
Depth to weeping from side of obs.hole: ! in, Groundwater Adjustment! Adj.faetor Adj.OroundwaterLevel
Index Well# Reading Date: Index Well levt'1
.�._ .�
PERCOLATION TEST Date
xlnt�
Observation Time at 9" .- --
Mole# y i
11
Time at G" ......._� .
Depth of Pere
I v D j Time(9"-6")
Start Pre-soak Time.@
End Pre-soak
Rate MinJlnch
Site Suitability Assessment Site Passed _
Site Failed: Additional Testing Needed(YIN)
Original:.Public Halth Division Observation Hole Data To Be Completed on Back—
! ou must first notify the
***If percolation test is to be conducted within 100 of wetland,.-You
Barnstable C41iservation Division at least one (1) week prior to beginning. �:
DEEP OBSERVATION HOLE LOG Hole#_L-
i Depth from Soil Horizon Soil Texture Soil Color Soil Other
I (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Surface(in.) Consistenc .%Gravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling .(Structure,Stones,Boulders.
c Consistency,%Gravel)
to C`
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,,Boulders.
Consistency,%Gravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency. ra I
.r
Flood Insurance Rate Map: /
Above 500 year flood boundary No— Yes
Within 500 year boundary No Yes
Within]00 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet-of naturally occurring pervious material exist.in all areas observed throughout the
area proposed for the soil absorption system?
If not,what is the depth of naturally occurring pe ious material?-
Certification
I certify that on CO (date)I have passed the soil evaluator examination approved by the
Department of Enviro mental Protection and that the above analysis was performed by me consistent with
the required tr �nin xpertise qndd
` experience described in 3:10 CUR 15.017.
• Signature 4 r •\ Date
4
Q:ISEPTICIPERCFORM.DOC
i
LEGEND HYANNIS
m RDUlf 28
PROPOSED CONTOUR
98 PROPOSED SPOT GRADE
9
EXISTING CONTOUR•
+ 96.52 EXISTING SPOT GRADE Rp�f6 28
1EXIST. 1 ,000G W— EXISTING WATER SERVICE ALICIA RD. m Q
5EPTIC TANK TEST PIT o %p
3 �
Q 9
U tv
43 j
—�- SITE
- 0
O I
! '��_-'-43 42 GENERAL N DRIVE
7 10 f // �i LOCUS MAP
TPL I
20 fc �� i LOCUS INFORMATION
' v I 44
(� Z I I ! ! TITLE REF: CERT:170685
/ z z 0 I ! ! Q PARCEL ID: MAP 310 PAR. 003
/TP- �= TI I L_O T! 3 7 ' I Y
J IAREA =! 9665 sff! —I
! O I I W O LAND I COURT PLAN 1 403 !— o 3
Ln x " ASSRI MA�31OPCL3� 1 ui o SEPTIC SYSTEM
W O-f !
~w —W_; _ - . _W_ W CATER REPAIR PLAN
(T LOCATED AT:
L J 247 BEARSES WAY
Q (n HYANNIS, MA
! 40 ML POLY El-r IER
— �5' ! f N PREPARED FOR
Lu s; -- --- MECRONES
Ofi EXIST. _ I DECEMBER 2, 2014
' \ m
LLJ
42 "
--- ---- _ �� �6 W OF90.00,
'yqS
RETAINING WALL — , CyG
-----' ! 40 ML POLY BARRIER o D RREN
P .�
EDGE EL 40.0-36.0 140
OF PAVEMENT G
HAMPS �,�
Y� HIRE T VE N I msIT00 2
' BENCH MARK MEYER 8c SONS INC.
TOP OF FOUNDATION
45. 14 P. O. BOX 981
E3ARNSTABLE GiS DATUNI, E. SANDWICH , MA 02537
PH. (508)360-3311
{ fax (774)413-9468
t meyerandsonstitle5@gmail.com
SCALE: 1"=20'
SHEET 1 OF 2 J#1540
T.O.F. NOTE: MAGNETIC TAPE TO BE PLACED OVER ALL COVERS
NOTE: PLACE RISERS OVER ALL COVERS W/IN 6" OF GRADE FINISHED GRADE (44.0)
EL: 45.14 F.G.EL: 44.20 F.G. EL: 44.0
F.G.EL: 43.50 •� VENT
' MAINTAIN 2% MIN SLOPE OVER LEACHING AREA
:n
° TOP TANK=EL. 40.50 2" OF 3/8" DOUBLE WASHED 3/4" - 1-1/2"
it. • . STONE OR FILTER FABRIC DOUBLE WASHED STONE
4" SCH 40 PVC
OEM
1o"I 6 (MIN. ®®®®®®®®®E EMW
A' TEE'S ARE TO BE ) ®®®®®®®® 3EM Ea
4" SCH 40 PVC 14" INV.38.80 ® IINV.38.60
1% 2 EFF. DEPTH ®®®®®®®®®®®
A' INV.39.20
l� 4' 2 X 8.5 4'
GAS PROPOSED DB-3 = 25'
EXISTING OUTLET BAFFLE EFFECTIVE LENGTH(H20) DISTRIBUTION BOX
I NV. 39.45 I NV. ELEV.= 38.40
EXIST. 1,000 GALLON SEPTIC TANK
OF
GAS BAFFLE TO BE INSTALLED ON ��� Mgss9� BREAKOUT
OUTLET TEE AS MANUFACTURED BY
o RR N M ✓+ ELEV.= 39.40
NOTES: TUF-TITS ZABEL, OR EQUAL r MR TOP CONC. ELEV= 39.40
1) CONTRACTOR SHALL VERIFY ALL EXISTING No. 1140 `� INV. ELEV= 38.40 ®® ®®
PIPE INVERTS PRIOR TO CONSTRUCTION ®®®®®®®
2) D-BOX SHALL BE SET LEVEL AND TRUE TO RFGISIE O ®®®®®®®
GRADE ON A MECHANICALLY COMPACTED SIX NITAR��'� BOTTOM EL.= 36.40 ®®®®®®®
INCH CRUSHED STONE BASE, AS SPECIFIED IN \� 1� �� 3.75' 5 FT. 3.75'
310 CMR 15.221(2)
3) REPLACE EXISTING 1,000 GALLON SEPTIC TANK SEPARATION 5.13 FT. EFFECTIVE WIDTH = 12.5'
WITH 1500 GALLON SEPTIC TANK IF FAILED, SEPTIC SYSTEM PROFILE
DAMAGED, OR UNDERSIZED. SOIL ABSORPTION SYSTEM (SECTION)
4) INSTALL INLET & OUTLET TEES W/ BOTTOM OF TESTHOLE EL: 31 .27 _
GAS BAFFLE AS REQUIRED (500 GALLON LEACH (H20) CHAMBER)
GENERAL NOTES: DESIGN CRITERIA **NO PROP INCREASE IN FLOW**
I. ALL CHANGES TO THIS PLAN MUST BE APPROVED BY THE LOCAL SOIL LOG P#:14562
BOARD OF HEALTH AND THE DESIGN ENGINEER. NUMBER OF BEDROOMS: 2 BEDROOM EXISTING/3 BEDROOM DESIGN
2. ALL WORK AND MATERIALS SHALL CONFORM TO THE REQUIREMENTS DATE: NOVEMBER 20, 2014 SOIL TEXTURAL CLASS: CLASS 1 (0.74 GPD/SF)
OF THE STATE ENVIRONMENTAL CODE, TITLE V. AND ANY APPUCABLE
LOCAL RULES AND REGULATIONS, EXCEPT AS REQUESTED BELOW: SOIL EVALUATOR: DARREN M. MEYER, R.S., CSE #1614 DESIGN PERCOLATION RATE: <2 MIN/IN
- 310 CMR 15.405 (1) (e): WITNESS: DONNA MIORANDI, BARNSTABLE HEALTH
DAILY FLOW: 110 G.P.D. X 3 BR = DESIGN FLOW: 330 G.P.O.
1) A 1.6 FT. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING
VIDED) GARBAGE GRINDER: NO (not designed for garbage grinder)
TO BE 4.60 FT (MAX) BELOW GRADE VS REQ'D 3 FT. (H20/`vENT PRO
Elev. TP- 1 Depth Elev. TP-2 Depth
2) A 4 FT. VARIANCE FROM 310CMR15.221(7) TO ALLOW LEACHING 43.10 0" 43.15 A 0" SEPTIC TANK: 330 gpd x 200% = 660 gpd, USE EXIST. 1,000 GAL. SEPTIC TANK
TO BE 16 FT FROM OWELUNG VS REO'D 20 FT. (LINER PROVIDED) A
A LOAMY SAND LOAMY SAND (330) = 445.94 S.F.
3. THE SEWAGE DISPOSAL SYSTEM SHALL NOT BE BACKFILLED PRIOR IOYR 3/2 / LEACHING AREA REQUIRED:
TO INSPECTION AND APPROVAL BY THE BOARD OF HEALTH AND THE 42.35 9" 42.35 8" •74
DESIGN ENGINEER.
4. ANY CONDITIONS ENCOUNTERED DURING CONSTRUCTION DIFFERING
FROM THOSE SHOWN HEREON SHALL BE REPORTED TO THE DESIGN LOAMY SAND LOAMY SAND
s6A/8 ENGINEER BEFORE CONSTRUCTION CONTINUES. 4002 39.98 38" STONE ON ENDS & 3.75' STONE ON SIDES: 25' L x 12.5' W x 2'D
5. ALL ELEVATIONS BASED ON ASSUMED DATUM. . C 37" C BOTTOM AREA: 25' x 12.5'= 312.50 SF
6. THE DESIGN ENGINEER IS NOT RESPONSIBLE FOR THE FAILURE OF F
THE CONTRACTOR OR OWNER TO NOTIFY THE LOCAL BOARD OF MEDIUM MEDIUM SIDE AREA: (25 + 12.5) X 2 X 2 = 150 S
HEALTH FOR PROPER INSPECTIONS DURING CONSTRUCTION. PERC TEST SAND SAND TOTAL SQUARE FEET PROVIDED = 462.50 vs. 445.94 REQ'D
7. WATER SUPPLY PROVIDED BY TOWN WATER SERVICE. ® 39.5 2,5Y 7/4 2.5Y 7/4
DESIGN FLOW PROVIDED: 0.74(462.50 S.F.) = 342.25 G.P.D. vs. 330 G.P.D. req'd
8. ALL AREAS DISTURBED DURING CONSTRUCTION SHALL BE RESTORED
TO A CONDITION AGREED UPON BETWEEN OWNER AND CONTRACTOR. 31.27 142" 32.15 132" PROPOSED SEPTIC SYSTEM UPGRADE PLAN
9. IT SHALL BE THE RESPONSIBILITY OF THE CONTRACTOR TO VERIFY THE
LOCATION OF ALL UNDERGROUND UTIUTIES, PRIOR TO STARTING WORK. PERC RATE <2 MIN/IN. SOILS IN (•C• HORIZON) 247 B EARS ES WAY, HYAN N I S, MA
10. EXISTING LEACHING TO BE PUMPED, CRUSHED AND FILLED PER TITLE 5. NO GROUNDWATER OBSERVED
11. 48 HOUR NOTICE FOR ENGINEER CERTIFICATION Prepared for: Mercones
12. THIS PLAN IS TO BE USED FOR SEPTIC SYSTEM PURPOSES ONLY System Design and Topography Plan by: SCALE DRAWN
AND IS NOT TO BE CONSIDERED A PROPERTY LINE SURVEY DMM
13. NO KNOWN PRIVATE WELLS WITHIN 150 FT. OF PROPOSED LEACHING ' Meyer, certify MEYER&SONS,INC.
I, Darren M. Me er, R.S., CSE, hereby certi that I am currently approved by MADEP pursuant to 310 CMR 15.017 N.T.S.
I to conduct soil evaluations and that the above analysis has been performed by me consistent with the PO BOX981
14. ALL PIPING TO BE 4" SCH 40 ® 1/8"/FT (UNLESS SPEC. ) requirements of 310 CMR 15.017. 1 further certify that I have passed the Soil Evol. Exam in October, 1999. EASTSANDWICH,MA 02537 DATE CHECKED SHEET NO-
requirements
NO WETLANDS WITHIN 150 FT. OF PROPOSED LEACHING 508-3622922 12/02/14 DMM 2 Of 2