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0109 BETH LANE - Health
109 BETH LANE HYANNIS A= 272- 169 - I Commonwealth.of Massachusetts 0? Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for WOW ry Assessments ; 109 Beth lane Property Address Michael&Maryann Bearae Owner Owner's Name 41N information.is / rx required for eve Hyannis, f every - MA -- „02601 11/11/19 page. (;nyfTown State Zip Code Date.of Inspect on Inspection results must be submitted on this form..:Inspection forms may not be alteredin any way. Please see completeness checklistat.the end Of the form. Important:When filling out forms A. Inspector Information �YaOv on the computer; use only the tab' Mathieu Rebello key to move your Name of Inspector cursor-do not N/A use the return key. Company Name 30 Norse Rd Company Address South Dennis MA 02660 Cityrrown _. State- Zip Code 774-722-02-71 SI-14140 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. Z Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the.Local Approving:Authority 4. ❑ Fails ` 7jr/yL- Inspeaor'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. t5irsp.tloc•rev.7126=18 Me 5 Official In spection Form:Subsurface Sewage Disposal System•page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 Beth lane Property Address _Michael&Maryann Bearse Owner Owner's Name V Information is required for every Hyannis MA 02601 11/11/19 page. Cityfrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 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 r rev.)t2812018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official, Inspection Form stem bs Suurface Sewage Disposal S Form:-- p. System Not for Voluntary Assessments a 109 Beth lane Fropeity.Address Michael &Maryann Bearse Owner Owner's Name infmation is required for every Hyannis MA 02601 11711'J19 page. City/Town State Zip Code Date of Inspection C. lnspection Summary(coat. 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 breakout or high static water level in the distribution bo c due to broken or obstructed ( )s p�p I e or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board.of Health): ❑ broken pipe(s)ore.replaced ❑ Y ❑ N ❑ NO(Explain below):, ❑ obstruction`is removed, ❑ Y ❑; N ❑ NO(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 ❑ NO (Explain below): obstruction is removed ❑ Y ❑ N ❑ NO (Explain-below): 3) Further Evaluation is Required by the Board.of Health: 0 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.7f262018 Title 5Offiicial Inspection Form:Subsurface Sewage Disposal System Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form \21 i9jol Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 Beth lane Property Address Michael&Maryann Bearse Owner Owners Name informat ion Is H annis required for every MA_ 02601 11/11/19 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 fall 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 waster 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 ❑ Z 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.7/2tMIS Tide 5 Official Ins pedion Form:Subswface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts IF Title 5 Official Inspectio'n Form Subsurface Sewage Disposal System Form=Not for Voluntary Assessments 109 Beth lane Property Address Michael&Maryann Bearse Owner Owner Name information is required for every Hyannis MA 02601. 1111109 page. Cttytl own State Zip Code ,Date.of Inspection C. Inspection S'umrrla ry (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%day flow ❑ Required pumping_more than 4 times in the last year NOTdue 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. ❑ Z Any portion of a cesspool'or privy is less.than 100 feet but greater than 50 feet from a private water supply well wit no acceptable water quality analysis. [This system passes if the well water analysis, performed at DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 4.0priij 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 faiisil have determined that one or more of the above failure criteria exist as described in 310 CM,R 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, M ❑ 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 mapped Zone II of a public water supply well t5insp.doc•rev.7/26=18 Title 5 Offiaal Inspection Forth:Subsulace Sewage Disposal System•Page 5 of i8 Commonwealth of Massachusetts -i o; Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 Beth lane Property Address - Michael&Maryann Bearse Owner Owner's Name - information is required for every Hyannis _ MA_ 02601 11/11/19 page. Clty/rown State Zip Code Date of Ins pection C. Inspection Summary (cunt.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"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 ® 0 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? Z ❑ Were all system components, excluding the SAS, located on site? ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example,a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp,doc•rev.712612018 Title 5 Official fnspedon Form;Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts Title 5,O fli `1 in' ct or i=orr 'CiSubsu`%ce,Sewage Disposal System Form-Not for Voluntary Assessments " 109 teeth lane Property Address ----------- Michael&Maryann Bearse Owner - M Owner's Name _ information is required.for every Hyannis MA 02601 11f11/19 page. CdylTown State Zip Code Date of Inspection D. System Information 1. .Residential Flow Conditions: Number of bedrooms(design); 3 :Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example; 110 gpd x#of bedrooms): 330 Description. 1000 gallon septic tank,d-box,two 6z6 leach pits Number of current residents: 273 Does residence have a garbage grinder? [❑ Yes No Does residence.have a water treatment unit? L Q Yes 0 No If yes, discharges to: Is.laundry on a separate sewage system?(Include:laundry system inspection Yes ,® No information in this;repo.rt:) Laundry.system inspected? .Yes 0 No Seasonai use? ❑ Yes No Water meter readings, if available last 2 ears.usa a gpd-116 Detail: 2018-37,000 gallons 20.17-48,0.00 gallons Sump pump? El Yes [0 No Last date of occupancy: current Date t5 nsp.doc•rev.7/26/2018 Title 5,Ofliciel inspection Form:Subsurface Sewage 0ispasel System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 Beth lane Property Address - Michael& Maryann Bearse Owner Owner's Name information is required for every Hyannis MA _ 02601 11/11/19 page. Clty/Town 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/A Gallons 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: NIA Last date of occupancy/use: N/A Date Other(describe below): NIA 3. Pumping Records: Source of information: last pumped 1 month aqo per owner 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.7126W8 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 8 of is Commonwealth.of Massachusetts �. Tile 5 Official-,Inspection Form Subsurface Sewage Disposal System Form -Not forVoluntary Assessments 109 Beth lane Property Address Michael&.Maryann Bearse Owner Ow Owner's Name information i e required for every Hyannis MA 02601 11/1111.9 -- page. City/Town . State... Zip Code Date of Inspection D. System Information (cont.) r 4. Type of System. Septic tank, distribution'box,soil absorption system El Single cesspool , El Overflow cesspool Privy Shared system(yes or no)(if yes, attach,previous inspection'records,-if any) Innovative/Alternative technol ogy. Attach a copy of the current operation and maintenance contract,(to be obtained from system owner)and a copy of latest inspection of the l/A system by-system operator under contract Tight tank.Attach a copy of the D.EP approval. Other(describe): Approximate age of all components, date installed (if known)and source of information: 1990 per BOH Were sewage odors detected when arriving at the site? ❑ Yes No 5. Building Sewer(locate on site plan): 24 Depth below grade: feet Material of construction: ❑cast iron ®40'PVC ❑other(explain): - Distance from private water supply well or-suction.fine' town water feet Comments(on condition of joints,venting,evidence of leakage, etc.): joints tight,proper venting, no evidence of leakage. 6insp.doc rev.7l26/2018 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 9 of 18 Commonwealth of Massachusetts f tA Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .1' 109 Beth lane Property Address - Michael & Maryann Bearse Owner Owners Name information is required for every Hyannis _ MA_ 02601 _ 11/11/19 page. Cityfrown State Zip Code Date of Inspection D. System Information (curt.) 6. Septic Tank(locate on site plan): Depth below grade: 16" 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: 1000 gallon precast Sludge depth: Q-11. Distance from top of sludge to bottom of outlet tee or baffle 33" Scum thickness 011 ._ Distance from top of scum to top of outlet tee or baffle 8„ — Distance from bottom of scum to bottom of outlet tee or baffle 14" -- How were dimensions determined? 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.): Tee's in place in working condition, no signs of leakage or over loading. Liquid level is equal with outlet invert. Tank does not need pumping at this time. t5insp.doc•rev.7/26QOIS Title 5 Offidal Inspection form:Subsurface Sewage Disposal System-Page 10 of 18 commonwealth of�MassachusetEs Title 5 Official, In Forrn fr Subsurface:Sewage Disposal System Form,-Not for Voluntary Assessments avti/,,y 109 Beth lane Property Address: Michael&Maryann Bearse Owner Owner's:Name information is required for every Hyannis MA 02601 page. C4,70wn --- - 11/11/19 State Zip Code Date of Inspection- P. System Information (cont.) 7. Grease Trap(locate bn'site plan): ° Depth below grade: N/A feet. Material of construction; '^ _ [❑concrete ❑ metal ❑fiberglass,y 9 ❑ polyethylene. n other(explain); NIA Dimensions: N/A Scum thickness N/A , . Distance fron-i top of scum to top of outlet tee or baffle N/A - NIA Distance'fromi bottom of scum to bottom.of outlet tee or baffle -- Date of last pumping: N/A Date Comments(on,pumping re.commendations,'iniet 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: .NIA Material of construction: concrete ❑ me#al fiberglass xP ❑g polyethylene -!other(explain): N/A z. a - r N/A ._ Dimensions: — ° Capacity: . N/A gallons Design Flow: NIA gallons per day t5insp.doc•rev,7rTM18 Titt 5 Official inspection Form:Subsurface Sewage.0isposal tystem•pegs 11 of:18 Commonwealth of Massachusetts F Title 5 official Inspection Form ¢� Subsurface.Sewage Disposal System Form-Not for Voluntary Assessments �y 109 Beth lane Property Address — Michael &Maryann Bearse Owner Owner's Name information is Hyannis required for every y MA 02601 11/11/19 page. Cityr'rown State Zip Code Date of Inspection D. System Information (cunt.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: NIA Alarm in working order: El Yes ❑ NO Date of last pumping: N/A Date 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 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.): box is level and solid with no sign of carryover or leaking in or out of box. t5insp.00c-rev.7/2612018 Title 5 official inspection Form:Subsurface� Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Officia inspection Form Subsurface Sewage disposal System,Form-Not for Voluntary Assessments 109 Beth lane s Prop;iy_Address - Michael&Maryann Bearse Owner Owner's Name information is required for:every Hyannis MA 02601 11111J19 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 10. Pump Chamber'(locate on site plan),. Pumps in working order: ❑.,Yes No*, ..Alarms in working order: P , D 'Yes C► 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: N/A Type: leaching pits number: 'e wo-6x6 ❑ leaching chambers number: w ❑ eaching galleries number, leaching trenches number,length: leaching fields number, dimensions: ❑ overflow cesspool F ., '` ' number:,*- innovativelaiternative system► n Type/name of technology: -- t5inspAbc•rev.7126=16 Title 5.0,111ciailnspection Form Subsudece Sawage Disposal System•page 13 tir:18 Commonwe alth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 Beth lane Property Address Michael &Maryann Bearse Owner Owner's Name information is required for every Hyannis MA 02601 11/11/19 page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) 11. Soil Absorption System(SAS)(cant.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): soil found clean and dry with 6"of ponding in both leach pits with no high stain marks found or signs of hydraulic failure. 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 Depth of solids layer N/A 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 :t5insp.doc•rev.7/26=18 Title 6 Official tnspec ion Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts : Title 5 Offici'al Inspection Form. 4 Subsurface Sewage Disposal System Form"'Not for Voluntary Assessments 109 Beth lane Property Address Michael&Maryann Bearse Owner Owner's,Name' -- information is a required for;every Hyannis MA 02601 11/11/19 page. City/Town. State 'Tip Code Date of Inspection D. System Information (cont.j 13: Privy(locate on site plan): Materials'of construction: NIA Dimensions N/A Depth of solids . NSA Comments(note c ohdition of soil; signs,of hydraulic failure; level of pondingi cflndition of vegetation, etc.); N/A t5insp.doc•rev.7r2612018 Titles Official Inspection Form:Subsurface Sewage.Disposal System•Page is of 18 ........__........ —_ Commonwealth of Massachusetts ?41 1 - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 109 Beth lane Property Address Michael &Maryann Bearse Owner Owner's Name information is required for every �annis MA 02601 _ 11/11/19 page. City/Town State Zip Code Date of Inspection D. System Information (cons.) 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: 0 hand-sketch in the area below ❑ drawing attached separately W nr��cw�y A . 8 A3 - 3Q y 3 � y- s6 es 3a _ 3 A � S cs .a r�P tt rev.726/2o18 Title 5 Official inspection Form:Subsurface Sewage D'g isposal System•page 16 of 18 a Commonwealth of MassachusiDtIts rD Y; t9 Title 5 Official Ins pe ction Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 Beth lane Property Address Owner Michael&Maryann Bearse O wners Name . information is required for every Hyannis _ MA 02601 A 11/. 1719 page. City/Town - state' Zip Code Date of Inspection D. System Information (cunt.), 15. Site Exam: Check Slope El Surface water Check cellar ❑ Shallow wells t Estimated depth to high groundwater: 20'+ r feet Please indicate all methods used1d determine-the high ground water elevation:. Obtained from system design pians,on record If checked,date'of.design plan reviewed Date Observed site(abutting.propertylobservation 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 maps You must describe how you established the high groundwater elevation; USGS top o maps show groundwater 20'+ Before filing this Inspection Report,please see Report.Completeness Checklist on next page. t5insp:doc rev.7%2612d18 Title 5 Official Inspection Fon:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts F Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 109 Beth lane Property Address Michael&Maryann B_e_arse Owner Owner's Name information is required for every Hyannis MA 02601 11/11/19 - page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ❑ A. Inspector information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 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 16 of 18 TOWN OF BARNSTABLE LOCA'�,TON ZAI SEWAGE # VILLAGE t4 ASSESSOR'S MAP & LOT o?'7-:Z-/,G INSTALLER'S NA E & PHONE NO. Oe/,Vcz �lrG2C' SEPTIC TANK CAPACITY G!S O l� LEACHING FACILITY:(type) �, � (sue) NO. OF BEDROOMS PRIVATE WELL O PUBLIC WATER _ BUILDER O NER I"ct La- DATE PERMIT ISSUED: /D d DATE COMPLIANCE ISSUED: VARIANCE GRANTED: °Yes No 1 y � . � a l..p N . � a S -- �P3 : ma-s ue No...�o._�[.�� ......v. . .... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tomitrurtinn ramit Application is hereby made for a Permit to Construct ( 64"or Repair QoY"an Individual Sewage Disposal System at: __... �.Y.=k.. - ......................a ..... ------••-•---------------•---•------------. ---...-•--------................----•---- L cation•Address or Lot No. ---------------•- - .............................................. Owner Address WULh -----.ec'-- .......................................-.......................................................... Installer Address � feet Type of Building Size Lot___________________________S q. U Dwelling_No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) `C1414 Other—T e- of Building ................................ No. of persons____________________________ Showers Cafeteria Q' Other fixtures .......-.............................................................................................................................................. W Design Flow........lj__57________________________gallons per person per day. Total daily flow_.____3 3__�5________._.._--_.....___.gallons. x Distic posal Trench Liq No capacity- gallons Length Total Lengthidth--___•--:-----Total leaching area_••Depth_ ---.sq. ft.'-" 3 Seepage Pit No------- ....... 'Diameter....9_NG-._( .__• Depth below inlet.................... Total leaching area___ ___________.sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed bY------------------------••----...._..__----------------------------------- Date--------------------------------------- Test Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water........................ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ �+ •---•---•-----------------------------------•••••••-•-••------------------------..._......_........_._..--•-----•-•-•-•-•-•----•----------------------- ODescription of Soil.................................................................................-----------------------------•----•----------------------•----••-••-••._....-------•-- x V W ------------•\----'-----------------------......•------•---•--•---------`-•--------------•---f-•------••••-----------....••--- ------••--------•--------------•------------------------------------- UNature of Repairs or Alterations—�nswer when applicable-__. .:. _ * -•--------- ST L,�R T�! .......... =-�-=-to---------1.c)_.....ff ......a!wMVLVL -------------------------------------------------------------------- ------ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has , been uissued/b-y the boar d of health. Signe V------------------- - ----- Application Approved -BY - ------------------------------------------------------------- Application L�ol�l� - e �--....--.. Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------------------------------- ----------------------- ------------------------- --------------- ---- ------------------------------------------------------------------------------------------------------------------------------- --------------------------------------- Dare Permit No. .................................. Issued -------------/o �! �� ------------------ ---- -.. f J ff�f q,,,�•` �''�_• °,� —"'- -per- -- No.../ .. - Fim ............. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE ' Appliratinn for Uhipasal Works ToustruetJinn ramit Applications is hereby made for a Permit to Construct ( Tor Repair (40 an Individual Sewage Disposal Systetp©at• ; �Pf "tom `r�G�'ih1S ...d_c:_.k. .. ... ......... ...................... ............................................ _....-- 1 - 1 CF o�ation or Lot No. f ' ...................................................... 112 r � ......:. -----'-#----------•-•............... ....................... .........f---------...----•---•-•-•--'-'Address•--•----------•---•----•------•-------'---- Installer Type of Building i Size Lot................ Sq. feet aDwelling—Np.' of Bedrooms.........._.:;.;_:...:...............Expansion Attic ( ) Garbage Grinder ( ) Other '"Type of Building ......................... No. of ersons. ......_ :__._....__.. Showers — W YP gP '"" 1 ( ) Cafeteria ( ) Other fixtures fi= ...... ---- ---•--------------- -............................. :.. Design Plow.... .R...� _......_ gallons per person per day. Total daily flow,—�_._R Ions. W � . t g P P P Y Y WSeptic Tank—I iquid capaci�`y�0.t?.._-gallons Length-;..._........... _ Width................ Diameter................ Depth................ x Disposal Trench—No._._.-_...•........•. Width.................... Total Length.................... Total leaching area--_•`_-_____________sq. ft. Seepage Pit No...�-.:--_.____-:--_ Diameter._ r ,`.___:_. Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed b a by.......................................................................... Date................................ Test Pit No. 1................minutes per inch Depth of Test Pit..................... Depth to ground water-----_.................. P4 Test Pit No. 2................minutes per inch Depth of Test Pit....:............... Depth to ground water.................. (� ................................................................................................................ O Des ription of Soil .....................................................-- •. --_---• ......°.... x . ! .. U ......................... f. --_---••--_ U Naature of Repairs or 'Alterations Answer when applicable - t- . �r...... `�� ��r f 111....!� e�% 1F ` ... ------ --------- --------- Agreement: , ,,'The undersigned agrees to install the aforedescribed Individual'Sewage Disposal=System in accordance with . the provisions of TITLE 5 of the State Environmental Code—The undersigned further,agrees not to place the system in operation until a Certificate of Compliance has been issuedrby the board of health. r Signe � �........-� ....�---- ------------------- �.. tj.... i - - re" r Application Approved By �<.�r.s. :�U. -'............................. ...... ..................... -----------...... ®�:// Application Disapproved for the following ream'.: .............-..................................... .............. .--...---------..... . .......... -------- ----------------- --------------=------------------------------ --------•----...---------.......f_.----------------------.._... ---------------.......----------------- .: ........................................ Dare Permit No. 96 U- ............................. Issued .---....... ---- ...----- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH [ i , TOWN OF BARNSTABLE (gErtifira#e of (fom liall THIS IS TO CERTIFY, That the Individual Sewage Disposal Systemoconstructed ( )!or Repaired by ........O1.p/i�/c°.P�./��.J./....r`k/' -/��[/ ( ........... . . ..... ................ ----=...............-- ... ... --- at ...�C� ..../9.e- 47...G..i/j. f .� t/�./1 �. •...................Installer ..................... _ p...................._-... ...._..._._____.__.-___............_.... 2 has been installed in accordant with the provisions of TITLE 5 of�The`State Environmental Code as described in the application for Disposal Works Construction Permit No (3_ ..:.... dated . .......................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CON -TRUED AS A GUAR TEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. f DATE... ..��.._. /.: ,. In spector�" ... A... -- . ................. .. �...p THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH �... TOWN OF BARNSTABLE ! e��— f FEE.. , d . r Disposal Works Tunsirudion 'prrntit Permission is hereby granted. . ..... to Construct ( ) or Repair an Individual Sewage Disposal System at No. L� ���°l'�'� �-� - s !eel....... -... Y ..................... •-- ' Street as shown on the application for Disposal Works Construction Permit NofJ ated. .!/ ._ ?G?_____________________ ......•-'•••-----••- .../ � . a�lf�'�'"'------------------------------- DATE.../.1-1-'-�.9 ........................................................... FORM 36508 HOBBBS IN WARREN.INC..PUBLISHERS LD-°C'`i T10N �o .y. SEWAGE PERMIT N0. IQ VILL GE INSTA LLER'S NA ME & ADDRESS JOHN A,, AALTO B.ArkH�€ 350 ,Walnut Street West Barnstahie, Moss-. ^^ 668 BUILDER OR OWNER or DATE PERMIT' ISSUED DATE COMPLIANCE - ISSUED �h w e I l 79 No..---....� f ............... THE COMMONVNEAL"TH OF MASSACHUSETTS BOARD OF HEALTH ..-----..-- ................OF..........................--•--.......-..._...------------................._....--------.. Applira#aan for Ui ip asa1 Works Tnnitrnrtiun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: -------------------------- - _... �_,__L -- _=Y or t No. �,,, r ....... ddress a .............. .............. --------------•--------------•--•-••........ ...........................•... � Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms_._....................................Expansion Attic ( ) Garbage Grinder ( ) 1:14 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Q' Other fixtures ---------------------------••••• • . . WDesign Flow...............5, .................gallons per person per day. Total daily flow..................a..__...._._...........gallons. WSeptic Tank—Liquid capacity./ gallons Length..._............ Width.... Diameter................ Depth......f•-----. x Disposal Trench—No. .................... Width ��_F...___.... Total Length......._............ Total leaching area._��._.......sq. ft. Seepage Pit No-------i............. Diameter....-•__ ..... Depth below inlet.....__........ Total leaching area._._._.._S_..sq. ft. Z Other Distribution box ( Dosing tank ) _ 0-4 - Date--� Percolation Test Results Performed by._._��_•---__-_--°_____ ________•____...._._____i______.__._.__._ _ _ '�—�— a Test Pit No. l.e —....minutes per inch Depth of Test Pit...l.2....... .__ Depth to ground water._-,.. fT Test Pit No. 2...._!!.......minutes per inch Depth of Test Pit-----!.�----------- Depth to ground water...............et--_--. ...... ... . Description of Soil-------•-�: .�.............::r� V .....•-••••••--•......_..:-•--------------------•---••----------....--------------------------------.......------------•----------------•----------------------------•-----..............._......---•••. ...........----------o........................................... ..................................................... -------•---••••••••••-----•••-----••••-•••......•-••••......---......... UNature of Repairs or Alterations—Answer when applicable........................................................:....................................... ----------------------------------•-----------------------•--------------•••-•-••••------------••--••••••---•-------•----------------------•--•-••--•-•••••-•-•-•-••------•-•••-••--•••......----_-•--- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iI'N 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b ued by t e iealth. /.� ►f Sigd. •.•••.•• ------------•••••• ....f t..i.. Application Approved By_..... . -.. .... �- .....--••--------•-•----- ...../-'tf_.- 7.1_.....••--- Date Application Disapproved for the following reasons---------------•-•----------••-----------------•-------••------•-------------•--•------------•••---.......-•---- -- - - --------- Date 6 Permit No. Issued // ? 7`--- -- -- - ----- -•--------- Date i No. •- -........... Fin;_........................... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .................. ........................O F..........................---...-......-.----------...........-----....................._. Appliratiun for llhipas al Workii Tontitrurtitun ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at ` L.931._6.14 �•r d� � +;�pro... .? �a ....... h Location Addftjs Ap / or t No .. ` .?fir �F ... a €c .. f t e ........ - ._ter..... ...... �`.� 6 Qwner ddress (� "?'L � " -Rt .......................y^ ......-,..,�.......... ........:a ............... �_............ Installer Address Q Type of Building Size Lot.................0..........Sq. feet Dwelling—No. of Bedrooms.....__:`'?...............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria d Other fixtures --------------------------------------- - - a W Design Flow......... ..................gallons per person per day. Total daily flow._.__..-------..--: -�-. '...........gallons. WSeptic Tank—Liquid capacity- ° .gallons Length.__. __.__.. Width...."? ....... Diameter---------------- Depth....`�'.._..._ x Disposal Trench—No..................... Width.... .......... Total Length............I....... Total leaching area....................sq. ft. Seepage Pit No.---_--_(............ Diameter.... . _. '.._. Depth below inlet.....': ._......_ Total leaching area._._. . :_.___sq. ft. Z Other Distribution box ( Dosing tank f ) Percolation Test Results Performed by..........................zt ?�' --------------------- Date.._... .""°-� a Test Pit No. 1 ` :.----minutes per inch Depth of Test Pit-- ....... Depth to ground water................ ........ . w. Test Pit No. 2......'`........minutes per inch Depth of Test Pit__--.':............ Depth to ground water.................Z. ..____ 0 escription of Soil.......... A..x - / U --••----------------------------•-•------.....••-----•-•-----------•--.............--------.....----•-•••-•................---..i.r.."... --•---------------....--•--•--------........•--•.......---....... W UNature of Repairs or Alterations—Answer when applicable............................................................................................... f Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT?,; 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Sied_ ' r�................................•--------•-•----•------------••------•• .......................--------- f ,�� / Date Application Approved By...... ... r - M �.._.._.... y, Date Application Disapproved for 'following reasons:..-----•----------------------------•-------------------------...-------•---•--•-----------..............-•---- ........................................................................................................----•--------•--------•------------------------------•------------------•...........-•------•--- -a t Date Permit._No ------..--••-•.... . Issued---------•----•-----------•---•--••--------------•-- 4r,. ----------••--------------------• Date s, THE COMMONWEALTH OF MASSACHUSETTS . BOARD O HEALTH '"-3 1.........O F..:.. ......... '!�'? . r.......................................... Tntifirib of TOutphatt r T StkTO .` y TI That the Individual Sewage Disposal System constructed (Z-7—or Repaired ( ) byV. f+ --------------------------------------------------------------------•----- at Inst has been installed in"ccordance with the provisions of ` o The State Sanitary Code as des 'bed in the application for Disposal Works Construction Permit"wNo.:.............��...___...._.__...... dated_._1" .�_."..��.'_....__..._._.._.. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE. Inspectors::: --.. ............... .........0.....-•---•---------• ... THE COMMONWEALTH OF MASSACHUSETTS BOARD 9F HEALTH �9 t i ..............:.OF......... . ' . ...................................................... � N .......... ............ FEE........................ l ur ntrttrtiun rrutit Permission ereb ranted e' -•------------•-•---------- to Conrt" ) or a air ( )� vI ual S �`D�.ssal Sys at No. ....... ..... V ..... ......... .....G� F_ . .......... ---. ............................................................... + ` treet t as show,fi`on the application for Disposal Works Constructions r it Dated /_" .' . ............ Board of th DA !/ WARREN. INC.. PUBLISHERS ------- --- K :T ICAL - :'SYS EM P!,R OF Y A A N I 15W,:GR DE= A Rl F CAL E,' OT- 70' S FDN TOP` S-CAL-F RADE. OVER TA'N k _;OV ER:AADE' 'T G 0 'PVC OR C I TEES A tN T BSMT 0 Cf6 'FLRA5.00 GAL -BOX: REINFORCED DIST-:� TO�13E INSTALLED �,O N A LEV E L STABLE-BASE 70 �SEPTI C 'TO-SE,'INSTALLED ON A S LEVEL-� STABLE BA 1/2 WASHED PEASTONE ALL : BRICK a MORTAR 'COURSES AS fa AROUND FREE OF, IRONS FINES REbUIREb TO'B R I N G,COV E'R:TO GRADE,' AND DU N -PLACE P I T L A C H I N G 24"C.ii A TO' 1 1/'2 WASH ED,CRUSHED MANHOLE COVE R �'Si I S .,'.'STON E ALL AROUND FREE OF BASE TO BE , i-EVEL EE� ETA I S IRON IN ES AND DUST I N PLACE FO R FI N G;RADE, SEE SYSTEM PROFIL SOIL ' AND PER A 10W E c0L Tr 4 DA IN �N 15'S 8 M P E R C., , RATE -kvv� 4 rvK INV.ELEV SEE' C. D' :SPOHR ,c W P. PAU L_ AA U LINE MITA I N L SYSTEM PROFILE TAKEN BY : ET , B Y, w WITNESSED. OPENING! S W/4 8 DATE T 'Q A�5, �.cp -?-STE -3/4 OUTER DIA. ai I 'WA A I N SIDE DIA 'IF TEST PIT 7GND ELtV +5 -TOTAL' 3 0 0 _TA -'AREA S, 0 0 0 A 2 9 S'F� L kr*%7 I _($ . j 3 B."st 0 ri�, S A�l D 5 0 M R:Y OT '14 3 tl- 7 1 D I A '0 T# 4 6 6 ;2 L 'EF FECTIVt D I A. BOTI PERC. HOLE OWN p D L E ACH I N G I T SECTI 0 N RE Q C>' 12-5 �0 0 NO LE DESIGN DATA : SCA NOTE: DO NOT RUN HEAVY EQUIPMENT OVER SYSTEM NO. OF BEDROOMS 40 C3 DISPOSAL B E T H AN E LEACH 1' 'GALS., NG PIT NOTES FFLUENT EST. TOTAL DAILY, TO BE 4000 P.S.I d 28 DAYS .. SEPTIC TANK GAL. 6 2 REINF W ro x 6 GA. �W. W. M. 0 0Tr NS AR E AVAILABLE 3. 2 AND 4 ' SECTI OWN E R S,! GE NERAL., N ES GREATER DEPTH IREOUIREMENTS 1 . ALL SYSTEM COMPONENTS SHALL E INSTALLED IN B NOTE: ' ACCORDANCE WITH TITLE5 OF THE .STATE 'SANITARY CODE 'ELEV. OR LOWER AS r E XCAVATE TO U DATEDJ LY 1 1977 a ANY rLOCAL RULES APPLICABLE. F AND CLAY CONTAINING REOUIRED TO-REMOVE ALL LOAM 2. ANY CHANGE TO, THIS PLAN MUST BE ,A!PPR D. BY'TH E -E:' EXCAVATED MATERIAL ATERIAL BENATH PIT. REPLAC OF HEALTH, AND CHARLESx D. SPOHR. MECHANICA LLY WITH CLEAN,CLAY FREE GRAVEL.' COMPACTED IN PLACE. : MPLETED PRIOR TO BACKFILLING,' 3. WHEN CONSTRUCTION IS CO NOTIFY THE ENGINEER FORI SIDE AR S.F. G' A L 4<3 5 r 198 S F.Q:,: -4 : : NSPEFTIlON EA= GAL S r FOUNDARON ELEV. MUST BE CHECKED WHEN COMPLETED. 0 T E -7 S. Q EA WITIiOUT WRITTEN ''TOTAL MUST NOT 'BE,,CHANGEb!" BOTTOM AR F. S. F/GAL:, GALS 5. THESE ELrtVS" Ax AREA S. F TOTALr Sre'a Gr ALS APPROVAL BY CHARLES'D. 'SPOHR 0 LEGEND� 6,�FOUNDATION INSPECT ON REQD. WHEN EXCAVATED, V + 5 0. EXIST. 'GROUND L R L E AN ' FINISH GROUND ELE 50.0 V j'UNDERLINED p DATE D E S C IR P Trj 0 N r REV. p LA PIPE NVERT. ELEV. A A Q>F_ A 0. M SYST E TEST PIT LOCATION I SPO S A L SEWAGE F 0 R SEPTIC TANK Ly, �tDERS N -BU [I DISTRIBUTION BOX C LARK- 4- N A C. Jr. LOT 2 BET H` LANE ' 4 PI rP E CrHERS.r.kA SP6 p I T 4"BIT.-FIBER PIPE TIGHT JOINTS fAY- )- HYANNA , C,D F H 0\E RAD M P R 0 PROPERTY LINE D E S I G N E D. SPOHR D AT E,:!5 D R A W I N G NO. s t DRAWN: SCALE:AS SHOWN MAP SEC PrCL LOT, MIN. CODE DISTANCE' 5 1 2 CHECK ED: C. D. S