HomeMy WebLinkAbout0121 BETH LANE - Health T U
121 BETH LANE, HYANNIS
A= 272 168,
i
i
e
i
Commonwealth of Massachusetts a�a-Aa6
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Beth Lane
Property Address
Jeanne Peters 10
Owner Owner's Name/
information is ✓
required for every Hyannis Ma 02601 09-2 -219
page. City/Town State Zi Code —
P Date o Ins coon
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 �(�
�# ` 1
filling ou p Vt forms
on the computer, •
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not
use the return Cape Septic Inspections
key. Company Name
52 Rivers.End Road
a�I Company Address
Teaticket Ma. 02536
City/I own State
508-280-3356 Zip Code
Telephone Number - S13938
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
_ a
2. ❑ Conditionally Passes
3. Needs Further Evaluation by the,Local Approving Authority
4. ❑ Fails
Inspector's Signature 09-22 2019
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.
15insp.doc•rev,7/26/2016
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments sments
121 Beth Lane
Property Address
Jeanne Peters
Owner information is Owner's Name
required for every Hyannis Ma 02601 09-20-219
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1 2
p , 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•rev.7/26P2018
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
m
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�,. 121 Beth Lane
Property Address
Jeanne Peters
Owner Owner's Name
information is
required for every Hyannis Ma 02601 09-20-219
page. Cltyrrown 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):
El 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 w ❑ 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.7/2612618
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
r
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Beth Lane
Property Address
Jeanne Peters
Owner Owner's Name
information is
required for every Hyannis Ma 02601 09-20-219
page. Cltylrown
State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privyis within 50 feet
t 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 functioningin
safety and environment:
a manner that protects the public health,
❑ 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:
This home has a H-10 1000 gallon septic that is under a H-20 load. A portion of the H-10 tank is
under an addition. The addition has poured concrete walls. There is a picture on the last page of this
report. I am seeking help from The Barnstable Health Dept. to determine if the tank can stay or if it
must be replaced.
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
121 Beth Lane
Property Address
Jeanne Peters
Owner Owner's Name -
information is
required for every Hyannis Ma 02601 09-20-219
page. Cftyfrown State Zip Code Date of Inspection
C. Inspection Summary (cont j
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 Y2 day flow
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
0 Z Any portion of the SAS, cesspool or privy is below high ground water elevation.
E] ® 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.
Ej The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section C.4..
• Yes No
the system is within 400 feet of a surface drinking water supply
El _E1 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=18
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
a
4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
L 121 Beth Lane
Property Address
Jeanne Peters
Owner information is Owner's Name
required for every Hyannis Ma
page. City/Town 02601 09-20-219
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 "yes" »
must indicate yes or no for each of the followingfor all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments ssments
121 Beth Lane
Property Address
Jeanne Peters
Owner Owner's Name
information is
required for every Hyannis Ma 02601 09-20-219
page. Clty/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design)`. 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 plus
Description: GPD
Number of current residents: 1
Does residence have a garbage grinder?
El Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes ® No
Laundry system inspected?
❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings,if available(last 2 years usage(gpd)):
Detail:
Sump pump?
❑ Yes ® No
Last date of occupancy: occupied
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurfac
e Sewage Disposal System•Page 7 of 18
i
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
t
121 Beth Lane
Property Address
Jeanne Peters
Owner Owner's Name
information is
required for every Hyannis Ma 02601 09-20-219
page. C1tyrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present?
❑ Yes ❑ No
Water treatment unit Present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use:
Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
It Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Beth Lane
Property Address
Jeanne Peters
Owner Owner's Name
information is
required for every Hannis Ma 02601
page. Clty/Town 09-20-219
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
I
❑ 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
El Tight tank. Attach a copy of the DEP approval.'
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when,arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 41"
feet
Material of construction:
cast iron Z'40 PVC
other(explain):_
Distance from private water supply well or suction line: Town water
feet,
Comments(on condition of joints, venting, evidence of leakage, etc.):
water was flushed during the inspection and it came freely.
t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
1 1 ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o rm
to Subsurface Sewage Disposal System Form -Not for Voluntary to Asses
sments ments
�. 121 Bet
h Lane
Property Address
Jeanne Peters
Owner Owner's Name
information is
required for every Hyannis Ma 02601 09-20-219
page. Cltyfrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 3211
feet
Material of construction:
® concrete ❑ metal ❑fiberglass 9 ❑ 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: standard H-10 1000 gallon
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle 33"
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 12
11
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.):
I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of the inspection the liquid level was at working level
and the tee's were in place.
t5insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form' -Not for Voluntary. . ^ ry Assessments
121 Beth Lane
Property Address
Jeanne Peters
Owner Owner's Name
information is
required for every Hyannis Ma 02601 09-20-219
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
` Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as.related to outlet invert, evidence of leakage, etc.):
k
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grader
Material of construction:
❑:concrete ❑metal ❑fiberglass . ❑ polyethylene
❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.tloo-rev.7126R018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ti 121 Beth Lane
Property Address
Jeanne Peters
Owner Owner's Name
information is
required for every Hyannis Ma 02601 09-20-219
page. Cltyrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping.:
Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
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.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage or solids can-jover.
t5insp.doc•rev.7/28/2018 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Beth Lane
Property Address
Jeanne Peters
Owner Owner's Name
information is
required for every _Hyannis Ma 02601
Clty/Town 09-20-219
page. state Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):,
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
El leaching chambers number:
El leaching galleries number:
® leaching trenches number, length: one appx. 33'
❑; leaching fields number, dimensions:
❑' overflow cesspool number:
innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7l26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
y� Subsu
rface Sewa
ge
ge Disposal System Form Not for Voluntary Assessments
121 Beth Lane
Property Address
Jeanne Peters
Owner Owner's Name
information is
required fo
r Hyannis
e. or every C Y/Town Ma 02601 09-20-219
page. ry 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.):
At the time of the inspection there were no visible failure criteria found.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow El Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Idle 6 Official Inspection Form:Subsurface Sawage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 121 Beth Lane
Property Address
Jeanne Peters
Owner Owner's Name
information is
required for every t!yannis Ma 02601 09-20-219
page. CltylTown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids _
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t
f
t5insp.doc•rev.7/26I2018
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
1
Commonwealth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Beth Lane
Property Address
Owner Jeanne Peters
information is Owner's Name
required for every H annls Ma page. City,I own 02601 09-20-219
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
the building. Check one of the boxes below: where public water supply enters
® hand-sketch in the area below
❑ drawing attached separately
S
c
d
3e
i,
DjJ cji"' Q [awe.
t5insp.doc•rev.7f WO18
Tide 5 Official inspection Form:Subsurface Sewn a Disp
osal posal System•page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
m
Subsurface Sewage Disposal System Form-Not for Voluntarl Assessments
.V,.•�' 121 Beth Lane
Property Address ,
Jeanne Peters
Owner Owner's Name
information is
required for every Hyannis - Ma 02601
page. Cltyrrown 09-20-219
State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
®. Check cellar
® Shallow wells
Estimated depth to high ground water: _11 plus feet
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:
El Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I augered a'hole to 11 feet'.
Before filing ths'lnspection Report, please see Report Completeness Checklist on next page.
t5lnsp.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
121 Beth Lane
Property Address
Jeanne Peters
Owner Owner's Name
information is
required for every Hyannis Ma 02601 09-20-219
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
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.7/26r2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
C. S.
Cape Septic Inspections
Title 5 Inspections Alternative System Monitoring
52 Rivers End Road
Teaticket Ma.02536
508-280-3356
septicinspectorrnike@aol:com
The following pictures are from 121 Beth Lane Barnstable Ma.The probe is on top of the inlet cover and
discharge cover is dug up in this picture,The.H-10 tank is under the addition. The addition has poured
concrete walls.
Thank you
Mike Bisienere
Cape Septic Inspections
508-280-3356
- r
J
C
' t st � x h •�'Y S`a
YY 4
o
A
06
i +,
s
- y Q• �
-
P
4
r l
r.
4 fi� .
{
t
i
i
fi
�IKE Town of Barnstable
Office: 508-862-4644
. � Regulatory Services Department Fax: 508-790-6304 t
BARN5rnRM Public Health Division
�
MASS.� ` � Thomas A.McKean,CHO
0-39. �+b
200 Main Street, Hyannis, MA 02601
Payment Receipt
Septic Inspection Payment received: $25.00 (Cash) on 9/25/2019 Permit number: 14133
!Owner: FREDERICK P &JEANNE M TRS PETERS r
jAddress: 121 BETH LANE, Hyannis
�
i I
{
I
{
P y
I
I
Town of Barnstable
"v Inspectional Services
BARN
% NAM
,r&o 39. Public Health Division 1.
200 Main Street, Hyannis MA 026.01
Office: 508-862-4644 Thomas A.McKean,CHO
FAX: 508-790-6304
I
i
October 23, 2019
Dear Mr. and Mrs. Peters, _ 7
The septic tank'located at 121 Beth Lane,Hyannis,MA was evaluated on 10/16/2019
by Michele Cudilo, P.E, a consulting structural engineer. This evaluation was conducted
due to an earlier inspection report completed by Michael T. Bisienere, which needed
further evaluation.
1
Ms. Cudilo determined that the impact on the loaded corner of the gable end to the septic '
tank below has adequate separation to not structurally affect the septic tank. Further, Ms. -
Cudilo has inspected the as-built bump out proximity to the septic tank and finds the p
construction adequate. The Public Health Division office will maintain these records on '
file. k
Based upon the findings of the structural engineer, the Local Approving Authority has y
determined the septic system "Passes."
1
Sincerely,
I
t
Pas01'ean. CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mal:ling\Conditionally Passes Letters\121 Beth Lane Hyannis Resolution Letter.doc
�FrtHE ram, .
Town of Barnstable
Inspectional Services
BARNf3TAOL'E, 1
039. Public Health Division
200 Maiii Street, Hyannis MA 02601 i
t
Office: 508-862-4644 Thomas A.McKean,CHO .
FAX: 508-790-6304
l
CERTIFIED MAIL#7015 1730 0001 4988 1142
October 3, 2019
t
PETERS, FREDERICK P & JEANNE M TRS
PO BOX 42 i
WEST HYANNISPORT, MA 02672
ORDER TO COMPLY WITH STATE I{:NVIRONMENTAL CODE, TITLE 5
The septic system located at 121 Beth Lane, Hyannis, MA was inspected on 09/20/2019
by Michael T Bisienere, certified"Title V Septic Inspector for the State of Massachusetts.
The inspection of the septic system showed that the system "Needs Further Evaluation
by the Local Approving Authority."
l
The Local Approving Authority has determined the septic system "Conditionally
Passes," under the`guidelines of 1995 Title V (310 CMR 15.00) due.to the following:
f
• The addition foundation is partially located over the septic tank.
f
You are ordered to either (a) install a new septic tank a minimum of 10 feet away from
the foundation or (b) hire an engineer to certify that the existing septic tank is structurally
sound as-is. The deadline for completion of the work is September 22, 2021, two years !
from the date of the inspection report.
The owner may request a hearing before the Board of Health if a written petition
requesting same is received by the Board of Health within ten (10) days.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF l IEALTI-1
Agent of the Board of Health
Q:\.SITT10Titic V Inspection Report Letters Mail in;\Conditionally Passes Letters\121 Beth Lane Fiyannis.doc
C. S. I
Cape Septic Inspections
Title 5 Inspections Alternative System Monitoring Yw
52 Rivers End Road .
Teaticket Ma.02536 C�
508-280-3356 3,«
septicinspectormike@aol.com "�
Enclosed is a replacement copy of the Title 5 report I submitted with the wrong year I had the year as
219. Sorry for the inconvenience.
Thank you
Mike Bisienere
Cape Septic Inspections
508-280-3356
DAtl S+elw4o tj
j.
f
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. !% 121 Beth Lane
u Property Address
Jeanne Peters
Owner Owner's Name
information is required for every Hyannis Ma 02601 09-20-2019
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
41111 52 Rivers End Road
ITV Company Address
Teaticket Ma. 02536 i
City/Town State Zip Code
508-280-3356 S13938
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); I have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ❑ Conditionally Passes
3. ® Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
09-22-2019
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.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
A
Commonwealth of Massachusetts
- —,Np Title 5 Official Inspection Form
Subsurface Sewage:Disposll System Form -Not for Voluntary..Assessments
12.1 Beth Lane
Property Address
Jeanne Peters
Owner Owner's Name --
information is
required for every Hyannis 09-20=2019.
page. cltyrrown Ma _ 0260"1
State Zip Code Date of tnspection
C. Ilnspection 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 1
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 thefollowing:statements. If"not i
determined,"please explain.
i
The septic tank'is metal and over 20 year's 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 septiclank as approved by the'Board.of
Health.
*A metal septic tank.will pas's inspection if it isstructurally sound; not leaking and if a Certificate of
Compliance indicating that'the tan'kis less�than 20Tyears old is available, l
El Y ❑ N ❑ ND(Explain below): y; 4
I
t5insp,doo-rev.7/26/2018 Ti lie 5 Official Inspection Form Subsurface Sewage Disposal S stem•Page 2 of y g. 8
.\
Commonwealth of Massachusetts
�k p Title 5 Official Inspection Form
i-
b Subsurface Sewage Disposal System Form -Not for Voluntary_Assessments
121 Beth Lane
Property Address i
Jeanne Peters
Owner Owner's Name —---
information is --
required for every Hyannis Ma 02601,
'
page. City/Town 09 20-2019
State Zip Podia, Date of Inspect_ion--
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.
I
❑ 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,sottl0d or uneven distribution box. System will !
pass inspection if(with approval of.Board of'Health)
El broken pipe(s)are replaced ❑ Y ❑. N ❑ ND(Explain below)
obstruction is removed ❑ Y ❑ N ❑ ND(Explain;below):
distribution box i's leveled or replaced ❑ Y' ❑ N ❑ ND Ex p.lain below):
(
El
,I
----- - ---_ - is
The system required pumping more than 4 times a year due to broken or. pip-(s). The j
system will pass inspection if(with approval of the Board..o Health):
broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):'
obstruction is removed ❑ Y' 0 N
❑ ND (Explain below): .
i
3) Further Evaluation is Required by the Board of Health:
I
Conditions exist which require further evaluation by the Board of Health in.order to__determine1f
the system is failing'to protect public heal th, safety-or'the,environm,ent.
a. System will pass unless.Board of Health determines in accordance with 310 CMR
15;303('l)(b)that the system is not functioning in a manner which will protect:public health,
safety and the environment:
t
Smsp.tlob rev.712612018 Title 5 6fricial Inspection Form:Subsurface:Seawa&Disposal System•Page3 of 18
Commonwealth of Massachusetts
-, Title 5 Official Inspection Form
b Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
121 Beth Lane
Property Address i
Jeanne Peters
Owner Owner's•Name
information is
required for revery dyannis Ma 02601 09-20-2019
page; City/Town v--
State Zip Code Date oflnspection
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 at,manner that protects the public health,
safety and environment:
. i.
❑ 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,iswithin a Zone.1`of a
supply, public water
❑ The system has a;septic tank and S,AS 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: ess.than 100,feet but 50 feet or
more from a private,water su I well**:
pp Y t
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;pres'ence.ofammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no tither failure criteria are triggered:A copy of the analysis must
be'attached to this form,
c: Other,
i
This home has a H-10 1000 gallon septic that is.:under a H-20,load. A portion of the_H-10 tar k`is
under an.addition.The addition has pou[ed concrete walls. There is.a picture_on the last page of this
report. I am seeking help from The Barnstable.Health,Dept. to determine if the tank can stay or if'it.
must be replaced:
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 orclogged SAS or cesspool
❑ Discharge or ponding of effluentto the surface of the ground or surface waters
due to.:an overloaded or clogged SAS or cesspool
t5insp:doc-rev.7/26/2008 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 4 of18
Commonwealth of Massachusetts
l Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Beth Lane
Property Address
Jeanne Peters
Owner Ow
ner s Name —
information is
required for every Hyannis Ma 02601
City/Town 09.-20-201 g_
page` State Zip,.Code Date of inspection•
C. Inspection Summary (cont:) {
4) System Failure Criteria Applicable toAll Systems: (cont.)
Yes No
Static liquid level in the distribution box'above.outlet invert due to an overloaded
or,clo.gged SAS or cesspool
Z Liquid depth in cesspool is less than 6" below invert or aVailable;volume;is less
than 11/.day flow
Required pumping more than 4 times in the last year NOT due to clogged or
Obstructed pipe .Nu Number of times`pumped:
t
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 e a,Zon.e 1 .of a public water,supply
well,.
❑ Any portion of a cesspool or privy is within50 feet of a private watersupply well.
Any portion of a cesspooLor privy is less.than 100 feet but greater than 5Qfeet
from a private water supply well with no acceptable water quality analysis, [This
system passes'if,--,the' welt water analysis, performed.at a DEP certified
laboratory,for fecal"collform bacteria iridicates"absent and the presence
ofammonia nitrogen and nitrate nitrogen is equal to or less,than.5 ppm,
provided,that n or.other failure criteria are triggered.A copy of the analysis
and chain of custody must be att'a"ched to'this form>]
❑ The system is a cesspool serving.a facility with a deSignflow 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 11 of a public-water supply well
t6insp.doc•ram 7261'2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�r Title 5 Official. Inspection Form
h Subsurface.Sewage Disposal System Form Not.for Voluntary Assessments
121 Beth Lane
Property Address
Jeanne Peters
Owner Owner's-Name
information is
required for every H annis Ma 02601 . 09-20-2019
page. City/Town State Zip Code,- Date ofilnspection
C. Inspection Summa
ry (Cont
If you have answered"yes" to any question in Section C.5 the.systern is considered a significant 4 threat, or answered"yes";to any question in Section CA,;Ibove 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 fgr a//inspections:
Yes No
i
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?
Z 11 Has the system received normal flows in the pr-evious two week period?
Z Havelarge volumes of water been introduced to the system recently or as part of
this inspection?
Z Were as built.plans:of the system obtained'and examined?(If they were not
available note as N/A)'
Z ❑ Was the,facility or dwelling inspected for"signs ofsewage back up?
El Was the site inspected for signs of break out?
Were all system .omponen:ts, excluding the:SAS,located on life?
® ❑. 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.slu.dg6 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-do
terrnihed 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))
r
t5insp.doc,rev.7/262018
-Title 5,01'ricial,Inspection.Form:Subsurface Sewage'DispoSal System-.Page 6 of`18� G
Commonwealth of Massachusetts
: - - ,( Title 5 Official Inspec-t` on Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,
n 121 Beth Lane
Property Address - --
Jeanne Peters
Owner information is Owner's Name -- -----
—
----
requiredforevery Hyannis _Ma 02601 09-20-2019
page. city/Town Statey Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms deli h: 3' 3.
( g ) Number of bedrooms(actual): —
DESIGN flow based on.310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus
Description. GPD
Number of current residents: 1
Does residence have a:garbage grinder?
`' � Yes Z No
Does residence have.a:water treatment unity ❑ Yes No
,If yes;discharges to:
Is laundry on a separate sewage sy%em?(Includedaundry System inspection
information,.in this report.) [Q Yes No
Laundry system`inspected? El Yes No
Seasonaluse? ❑ Yes Z NO
Water meter readings;if available,(last 2 years usage(gpd)):
Detail: `.
Sump pumps - __.__.�- , ' _ �•
Yes Z No
Last date of occupancy: occupied
Date
t5insp.doc•rev.7/26/2018 Title Official Inspection,Form:Subsurface-.Sewage Disposal System•Page 7 of 18 -
Commonwealth of Massachusetts
,F Title 5 Official Inspection Form
Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments
.� � 121 Beth.Lane i
Property Address ..__. �„� ,
Jeanne Peters k
Owner Owners Name
information is
required for every Hyannis Ma 02601 0940-2019
page. City/Town State Zip Code ,Date of Inspection:
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203);
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.:): —
Grease trap present? ❑ Yes ❑ No
Water treatment unit presents El 'Yes ❑ No
If yes., discharges.to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the.Title 5 system?` ❑ 'Yes ❑ No
Water meter readings,if available:-
Last date,of occupancy/user
Date ,
Other(describe below):
3. Pumping Records: {
Source of information: 1
Was system:pgrnped as part of the inspection?
Yes Z No
If yes, volume pumped:
gallons
How was quantity pumped determined? —
Reason for pumping:
i
t5insp.doc•rev.7126/2018 TiUe,5'0fficial Inspection Form:.Subsurface.S"agepispbsal Syslem•page 8 of 18
Commonwealth of Massachusetts
---i Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/ 121 Beth Lane.
Property Address
Jeanne Peters
Owner Owner's Name
information is
required for every Hyannis Ma 02601
09-20-2019
page. City/Town
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 an '
y)
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 1/A system by system operator under contract
❑ Tight;tank. Attach a copy of the;DEP approval.
Other(describe):
Approximate age.of all components, date installed (if known)and. source of.information:
Were sewage odors detected when arriving atthe,site? ❑ Yes
® No
5., Building Sewer(locate on site plan):
Depth below grade: 41"
feet _
Material of construction:
cast iron 40 PVC ❑ other(explain): --
Distance from private water supply well or suction line:- Town water
feet
Comments.(on condition of joints, venting, evidence of,leakage, etc.:):
water was flushed during the inspection and it:came freely.
t5inspaoc•rev;7/262016 Title 5:0Kcial inspection Form:•Subsurface Sewage Disposal System..Page 9 of 16
commonwealth of Massachusetts
Title 5. Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
121 Beth Lane i
Property Address - —
Jeanne Peters
Owner Owner's Name —. .
information is
required for every Hyannis
page. City/Town
Ma 02601 09-20-2019
. --•- ----
State Zip Code Date of Inspection
D. System Informaton•(cont.)
a
6.. Septic.Tank(locate on,site plan):
i.
Depth below grade: 32"
feet —
Material of construction:
concrete
metal ❑fiberglass ❑ poi eth lene
Y Y M other(explain)
l
1.-.
If tank-is metal, list age:
years
Is age confirmed by a Certificate-of Compliance? (attach a copy of certificate) Yes [Q No
Dimensions: standard H-10 10Q0 gallon
Sludge depth: 3,
33 . . i
Distance.from top of sludge to bottom of outlet tee or baffle ---
Scum thickness 1"
Distance from.top of scum t0JOR of outlet tee or baffle
Distance from bottom of scum to bottom of'outlet ee or baffle 12
How were dimensions determined? sludge judge
i
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage etc.:)`
I recommend the new owner put the septic tank on a maint, plan with,a,local septic pumping co,
based on the future use of'the-home. At the time of the inspection the>..liquid level was at working level;
and the tee's were in place
. 1
4$insp,tloc•rev:712612018 Title 5 Official Inspection Form.Subsurface Sewage Disposal
System•Page 10 of 18. -
i
i
Commonwealth of Massachusetts
IF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l�
v/ 121 Beth Lane
Property Address _...._.�.y..�._..�:LL�.
Jeanne Peters
Owner Owner's Name— —
.�.....�
information is ,
required for every Hyannis Ma 026.01 09-20-2019
page, City/Town
Sfate Zip,Code Date of inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan);
Depth below grade:
feet
Material of construction;
concrete, ❑'metal
fiberglass ❑ polyethylene ❑.other(explain):
Dimensions: - ---
Scum thickness
Distance from top of scum to top of outlet tee or baffle:
� I
Distance from bottom of scum to bottom of outlet tee or_baffle
Date of last pumping:
Date.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural.integrity, .
liquid levels as related to outlet invert, evidence of leakage,
8. Tight or Holding Tank-(tank must be pumped at time of inspection).(locate on site plan):
Depth below grade: -
Material of construction:
❑ concrete ❑ metal
❑fiberglass ❑polyethylene ❑ other-(explain):
Dimensions: _
Capacity:
gallons —..——
Design Flow:
gallons per day, -
l5fnsp.doc-rev.7I28I2018 Title 5 Official Inspection Form:Subsurface Sewage.Disposal system•Page 11 of 18-
Commonwealth of Massachusetts
_5 Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Beth Lane
u Property Address
Jeanne Peters
Owner Owner's Name
information is
required for every Hyannis _ Ma. Q2601 09-20-2019
page. CityfTown State Zip Code Date of Inspection
D. System Information (Cont.)
8. Tight or Holding Tank(cunt.)
Alarm present: ❑ Yes ❑ No
Alarm level: . -- Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches,,etc.):
Attach copy of current pumping contract(required). Is,copy attached ❑ Yes ❑ No
9. Distribution Box-(if present must be opened)(locate on site plan);
Depth,of liquid level,above outlet invert 011
Comments (note if box is level and distribution to otatlets;equal; any evidence of solids carryover, any
evidence of leakage into or out of box, etc.).:
At'the.time of the inspection the liquid level was at working level and there were no visible signs of
leakage or solids carryover.
t5insp:doc•rev.7126/2019 - Title5 Official Inspection form:,subsurface Sewage.Disposal System•page 12'of 18
l
Commonwealth of Massachusetts
r
itle 5 Official Inspection Form
Subsurface Sewage Disposal System Form --Not for Voluntary As I
ane
121 Beth L _
v- _
Property Address
Jeanne Peters
Owner Owner's Name
information is -- -- !
required for every H annls`_ Ma 02601
page. City/Town �" 09-20-2019.
State Zip Code Date of Inspection i
D. System Information (cont.)
10. :Pump Chamber(locate on site plan):
Pumps inworking.order
❑ Yes ❑.No
Alarms inworking order. ;
❑ Yes. ❑ No`
Comments (note condition of pump chamber., condition of pumps and appurtenances, etc:)'
If pumps or alarms are not in working order, system is a conditional'pass.
11. Soil Absorption System (SAS) (locate:on site,pI n;excavation not required); I
If SAS not located, explain why:
Type
❑ leaching pits number:
❑ leaching chambers, number:
❑ leaching galleries number:
leaching trenches number length: o.ne apPz_33'
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: --- ----
t5insp:doc-rev.7f262018 Title official Inspection Form:qubsufface Sewage.Disposal System-Page 13 of 18
t
Commonwealth of Massachusetts
:= Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
1'21 Beth Lane
Property.Address
Jeanne Peters-
Owner Owner's.Name -
information is H annis
required for every Y Ma . 02601, 09-20-2019
a e. City/Town/Town ^.. i.
p g Y State Zip ,ode Date of Inspection
D. System Information (cont.) f
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, Signs of hydraulic:failure, .level of ponding, damp soil,condition,of
vegetation, etc.):
At the time of the-inspection there were<no visible,failure criteria found.
l
12. Cesspools (cesspool must be pumped as part of inspection) 1,1ocate on site plan):
Number and configuration —
Depth—top of liquid to.inlet invert - +<
Depth of solids layer
Depth of scum layer t ':
Dimensions of cesspool --- -
Materials of construction
Indication of groundwater inflow ❑µ Yes ❑ No
Comments (note condition of Soil, signs of hydraulic failure, level of ponding,condition of vegetation,
etc:):
l.
t5insp.doc.<rev.M6t2018 - Tiile.5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 14 of 18
t
I
Commonwealth of. Massachusetts -
-- t
IF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1
f 121 Beth Lane _
Property Address
Jeanne Peters
Owner Owner's Name -- —
information is F
required for every Hyannis Ma 02601 - 09720-2019
page. cityfrGwn State Zip Code Date of dnspection
.D. System Information (coat.)
13. Privy(locate on site plan):
Materials of construction; —
Dimensions —.... �_...
Depth of solids
Comments (note.condition of soil, signs of hydraulic failure, IeVel of ponding;condition of ve
etc.): getation,
j
i
j
i
t5insp:doc rev.,7l26Y2018 - Tdle 5:Offical Inspection;Forn Subsurface-Sewege Dispbeat System•Page 15 of 16'
i
i
Commonwealth of Massachusetts
t
- = Title 5 Official Inspection Form
y p
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� 121 Beth Lane
Property Address — -- v
Jeanne Peters
Owner Owner's Name
information is
required for every. Hyannis Maw 02601 09-20-2019
page. City/Town State Zip Code Date of Inspection
i
D. System Information (Copt)
• t
14. Sketch Of Sewage Disposal System: '
Provide a view of the sewage disposal system; including..1ies 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
J
p ^ f"r LOT-CO!N
gr
{
A - Z
a
_ i P
ST
7-S
t
t
tSEnsp.doc-rev.7125/2018 Title-5 Official Inspection Form:.Subsurface:Sewage Disposal System Page 16 of 18 -
a
Commonwealth of Massachusetts
Title 5Official Inspection Form
-- Subsurface Sewage Disposal System
— l' p Y Form Not forVoLuntary.Assessments
121 Beth Lane
Property.Address
Jeanne Peters
Owner _
Owner's Name- _ I
information is
required for every M annis Ma 02601 09-20-2019
page. City/Town State. Zip code Date of Inspection
D. System Information (cont.)
15. Site Exam:
i
Check Slope
Surface water
Check cellar #
Shallow wells
Estimated depth to hi
gh°ground.water: 1�lus feet
feet
Please indicate,all methods used,to determine the high groundwater elevation:
r
F-1 Obtained from system design plans on record
i
If checked, date of design plan reviewed: — --- ----
Date
, t
Observed site (abutting property/observation hole:within,150 feet of SAS)
❑ Checked with local Board of Health'-,:explain:
Checked with local excavators, installers-(attach documentation)
Accessed USGS.database-explain:
You must describe how you established the high ground;water elevation:
1 au eyed a�hol.e to 11 feet.
Before filing,this Inspection Report, please see Report Completeness Checklist on next page.
t5lnsp.doC-rev.712612018 Title 5 Otficial Inspection Form:Su Sewage Disposal System+Page 17 of 18
t
Commonwealth of Massachusetts
--_01P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluriiary,Asses.sments
121 Beth Lane
Property Address
Jeanne Peters
Owner Owner's Name ---
information is
required for every H annis�_ Ma C26o1 f
City/Town 09-20=2019 l
page. State Zip Code �. Date of inspection,
E. Report Completeness Checklist k
Complete all applicable sections of:this form in of:
A. Inspector information, Complete:all fields in this section.
Z B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
Z C. inspection Summary:
1,2, 3, or 5 completed as appropriate
4 (Failure Criteria)_and 6(Checklist)completed
Z D. System Information:
For'8: Tight/Holding Tank Pumping contract attached
For 14: Sketch of Sewage Disposal,System drawn:on pg. 1.6 or attached.
For 15: Explanation of estimated depth to high groundwater included I
i
I
j
t5insp.doc-rev.7/26/2018
Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 18 of 16 I
t � � tf� F � � ' �rt=ro s r � 7.. �' �?�"��. •`a. tea' �" -,tr,rtj, 7 '` (t
a p .
i
1
.�.�',�, via. _. � �� ����p� r � �� �, � �' 3���`»� °'� �e4fi- �� � �,Y� �:' r .yr�'�'•
n �°j y
w S
N
k
P
t
I, i
,3
-
z
#s,�y.?e � "`i�`*��*s.•'� .,, -'. _` '.,' Y.�' t 3a�` 3 ��, "#° .�.` rs�'a ��,„' r. >A, a .�,,.;qr ".� -�.+ ,�
°'_�'`"''�1'a ,�. t"`�- � ''�`�w'®e:�` �.,,�es.:;p.� .. ...,.,,-n..:., :�_ :• r xs+' r,. 'r3 ,5�,`�*4d,:. '�:� •P K� - "w.. •`Aay ,."� £ w4".;,� tY.'.,ry. 4r �+de:�'+,..._
='i;� :rwc'�, -... ^ .,y, ,� 'a�,:,. "pr, i"°E, a'•, r .�—...�,�+,m <� .,.:' }. ". -:� �' r t,;� ;P� Y.. t ��a?a �'��"P s'�.. _
�& ,is:..,• .�..t:- ___,�,.�,,,+:`,�-. 4 ,� 4#�. =erc,.w,-�' �" t--< 5hn t. 'dr rt."Si s na ��Y a.'3. �" S•' &
#aTy.,+. sx.M ..,.�.,' .., 'r�, , a .^++ `,. .,'♦,. Yr'1.,a 'fi 8:t 2� V ��
R
�. 'm t?ty. a� ,'� ?. ��^itf��: r I.as. ,� °�•�m,t
N 0
' k
Pit— k
a
' '
p � g
`r .+.. ..:.�+• 6 "�
s„
x
t
.Q
,
#
t 1 I2
c
a Fg
b
r
ti r
i
}
y
r
z.
fr-
a �
x
"T,
IC
v
" rY-P
�° .�..�s hry. .••-�^ ate. ': � '"C �s�..
" a*
�y
h
+y
rz
r
a#''
S a }" aP a, „-.. zvi ��n G✓" �� ri`�`ma �� k.ai �.^"' V �`^p�
� �r� *i.: `+�: `�.a`�iV�ct.•" ,1�; '...a ,?y '' ,..;, �,. d.. f'�:>-, t{, ,.4 �,?�� �"s;';^��+`°r"�.. " 10-11,
� � •,.��•,
,
�.a
,�= A �`�� � .r„ �i ` ro+Y"'�'tit���cy Tr;q Ik�.7L•g!. z, e,;..' c "�..+.'s? `d,%4;r�,' :3 �?t i �, � ;, «r ..�}�', '���y .,,_ 9.
P�yJ:•:j3�a.p � ,ln "1�, �� p�,' �' �' r+"�� U cp„�' :��`-;_�`,. ! •+t's,' .., a in�� t'"''
\a '�11C St��+ �^4�' ,��",. 4i� �: .1. 4 �•�'Jri��. .�. ��,� .. d' 6 \t tity �:r � � si'. +�"�i ''�.
f��,�j •�- '�iri4 +v..nt�G +t a _ , V.y �' ♦ 4 C` t,s'awr' qr'
,
V. '� rr ��V'��''+�'�' +�"r��rti�t ri`r�, '��,t,�d'•'"R�'• z S''` •° r "�4 rnl5 Y� , x 'A�'� :��,. � ? �
yta •�i`C�1 4� ,��+! �';l '��M �.i",✓'r- v-ytf' ff. y � � 1( - /� I~j" Y :f f .. 'ra!° ::i.
}��•'.�'�.��.1.4t��Iy.s `','"S.?�' ,:.-,t�P i`�ols'lli
�{ ��.a "dta.., yDt ,P' _ ` ;f ,�* .x't �'�'' ?-'kid, "•FJ.�
',• -al
4
t.,i *4 •.;,,' 'G ,� `6, ., �{ t a¢4 �...,e •, �z',.�.,�,-tc c;y r. :xa" di �5,,- !- �Y d:, `t ',� �: �• �4 5
kt �• .c^Q+9r vx�!„w-0,` d .yam#• LL�S.tC a r;h,:+Z S yl d'-' a ,t , ,' {� y' t,� 7,.` �aai,
��!, � �• .tP S't-'�aP't>.�ti��'c 'f •4'�i'.r,S+..i'�. .i°�t � ar� .v^�°`` �"*-$`� j w"`,"`*,lr"� o@`... �"{'S^S"`CtY� ^,�:: ..t t� � r-i.
d• �4, r A'�,�.��rx�u�,r- �_:�2�+'�•�p''t'^ �. a`- � - l *.yam '''t ��i ,� "�Ta t� •l�u.. 4
k sA
,:.: Yr' ,sA?�� �f`*�lm` �`I ��F t e��y�Ca`-,� �a �� d`r¢ r t'}?� �..�'h^. J. y� v `t�'�'"`'asro's "�i�. "�; 4�' �•�,�f�' �'yt�
S�;%'n�'�1 w-.�`b� a iw�# �'. v'/p�i ,�ad ��s'��Y ��:.;�E •,;r-. � r �' •�'`'..;1.+ .-'-F 'sa � y,/��a� � �3•.••:` :-.c'+P`�x+,R E� ��..�* ��:
�� .1-yp-fi,?r .t.q�.:� tt�,a1a. d 3-" > •tt IA}�. Me „•' ` ��.' �` :I �` :'aat � , �.�.� .. �n .� � t
� ,1��}t'c.LL,,�� a' ';,.i�•.,.y,,:},t� eu�a y+'vC. tc ;?'h>l4t ' ae� .'\t� $ --7' a°.� �, .,X, s..px>.., �,
A"3��i:4��F,�,�'`�.��j./•
�w.tt, �';�--j tr?"k.,;� 2{.�''F,*/�"" xYr �'`,,e v�'rC �t"'�.-F 1 .�.� "'w,r/ `•;�w.;- � �w� ��.r .°��4
p' ��>p � lr>,�� 4 p: a� tr"ri 'a,.. ! � "4 "r" I '.�rR ;j•. .� r8r. ' fix. i���44
JF'',
/'j• I rl. � �3.y6 ='AJ 'f..`Y ;{4-1,S �Tw+Yy�-f, - ' C T S �'�!
�� y;,.,:s.a�v'. ,".ne sy�3"�,�.:w,� �u a,;: �,�y .s... t�, {' �.� e�l7t C..�+•'4 y,�� � �, x � e*'k
.* �) lS�! Y,�,1�. y`i�'yS 1 ��a � 'fir..•.-� a/�.t`0 i� -� "P+<SC 0 '�„.;• •f�,
{ 4y 9 1`3.. ���,S,� 4 \ra c ,v-•* a ; ,r l��`atry^�`i Yr7 � �. �s. s b :�., ,`. �,. _ �.,..
l! '�Gw'� i�1;�,.� '���e�- x ,.� X 1�jda `ka. � .�-- .ti'- 1s _�E:• t.� ,r �,�r, _ .�_'R
-
,i ✓�
�+1 r: '+5"ws'4`"z��f� y`'`r� '-�A'�F..�T".,"•�1b�3iihb,���"��"_1'i ro '. 'e. }; / r ,r '�1�„� :� ,� -, ,ter" W ^,3"'�'
� prY �s".� �'+f a '"�'r'�'rA�a3 v3 ���'W``s"��`�` f- ri' `�n•Y d � / 1 '�" :'"w"4 \ i y. �IK ''�''
n A
,
a:"�+'v�•'rt"-W ` .fi" y .�r ;}Ct '^ ? r° "�'. 'hsY'`� ��P..; S: °' .,�'� �, 1':•'fr as1"t/, `'' P`'�,
ta :91 r r•: } .,}�v!*�'Sa.#:p,•�c��.>Y,r^��„y;. �� t s '"+� ,�'; "�` xras. J..J �r
yA � ���� '� i ^�4, �r"!' �,�, ���cl ��A r ky .�d?) �'' ," � ��' � \ it , 1' ."�" � � 1 ;+•r' tY�
yy�-",'3,..`p`•R!<✓ vim:>I•,
.,h •:?{.^ ., - ,+ram s` �.4r'i l iq 3• °s® .rlv, ++* ,., �, a t
A � � vL}r,i3r''`,.?r�iX+pi•�`•r ���`.e4.•sr•+. t et ..l t }P .3.. �. a° r� �'`\::t.�. � _
'.:.1. .:.a,I,�TK:•" t "k'tA� ". � '+w. - .. y, 'w,.: y'''�. ,t ..:'.`�•*„T.; � U=LL. .'• � Z y ' �` �as,`.;a".��as�°T r•y,�• -,�,c L.t
� •S` J61' '" ..'.f,•, ,���^.•h,.'- `� y7".�,� '^. .,n+ .rr r >l:' .. •( i,{. _ �{ `.�"7i,..,.b,•.
yam.
�
.,/ `V":?+... st!1',.k.. 3 i_r ,I, !� c s.., •a�'+� t !..L•t1'`lis.� �� �
�.
:... .+,. : .. :,r�. .i}'IJ r._7 •FJ�' ,Y`s�).t,7•it=. +�A"^'-,..,1 .,f� � .f :l .: � ' -"'S%r "' .. �
-� f ' a• ;$ `'`.r,t.�,ld 'r, �, � y,�� .gyp" �.K .6: �. "fi'�_� •� 'i,�,�.` '`_; '..�" �"�y�., 'd�'+
�r: '. ^. t,.rror�•t� x ^A 1��.*\-i' �'�-Tye..w:J;j� m�..Y•. •� x:_ lFf' {�'�,G'� ,•i's. - _ -!•y czw,.
SV
t }
r �.�. ��. k'd! mVu. r,� „r .�-i ;.�.�l'''^� �c• ,l+c ti ,r ,S' ',1{,��.iut '.Y '" ,.. - ..� '.'f '� y '-�
t,y ,,�may3 �y`,�,
'*�" ��'.r'�" .el',;° s'i .,�''>.,t«, 4 �' '` s#' e'�w .A .ore. A `. t *4�'x .. �...,,� •'
R5
. � ..; �.. �� ..rt t 1q,`.7,§S�t. �- x.�� Il-r sr�l.�"y7gry r.. er ;. � �� ,.v. F^'-: c�l '•--�, .,.s/ti_`.:�".w.�,,;+ * 4 � ;�,;�°
.. .'� :i• -. S«F4 h,�s yB^° !i�"�':?#t�(,•,+�4 n S.` '°�,r� . ��, 1'�'' ,f,>71 �!�(':j` Tk�r b�r ii�T„yi'` �•w. t + ;�'i._ -•S'O''. -$r'`l F � rt'-'�,
, i ✓'rAl}��t .3•,�.y`•L {$`�1.�",�a"'t„ 47� _ �3« ±�.. i�` �,6 W a� ` ',:,... v,.^' ,.�'* �g?',w,fir f' �•T„-"�+
� ,-1k, 4 f .,� '+w,+ .:j^�2C �3;er. ��•`. P� +a, �t"�.+oir�*:. \;,�-wr�eY'
. •S,e "ar'Q:• �{y. Tt'�,, t- a`.} .,..i. T,j `$iA ,s p.. aye 4,.., ;�. .k ,s 'kiPI '• '€. r ,'?°6 !.w' t `:bj
�:,fie., .,. +.cam.. ���"•.: ',ri,�-.. �c.�^'T.I":c: `*w t X`3� 'r,•-e..t''�•y: t',f,.�'�'h'yi� 'C'. n "^" 4, t�.�ti.-., r 't •�9"'+ �.y«.. '." '
� � >aS�� '..',.`-.-,. .^:. J is r* 1 ::5�'S r, r-Yc t i '` t.n.� � r �' -w,m' � �'( tw-: u .i �".»�y,��+ •i:. .r• �,,
/.tf� .. ::iH,.• a:. ,rs�,„, ,w+. ,f r?d�.�,tv.,;,..'. .,,i,,�in:. 'I9•-r z+t�� x � ,7'l 'a. ��� ..�w, r.. •.y s �
7' _ .,. i ,. .• .,�.r r.^ �3 di.c _ -w &:g... �'�+.., :� t ,� ,y��aw„w<:.r, ,a 'rte:' *7,� o rtlAe�Iv �.'''�*!P ! '1.'".1'
•- -r.. , �q re\� )) ,!�.: .. .�<4}•.p.y,�t�+-'ta' ,may.. 9;t.-.. tom, s'�A�r _ 3� •Y., a �,.pk � t. ;,�• a. ww'i �`:�*.�J�'�'�r�u
- i / h"' IS t4 :�.ly�+�1a'r-q�-w- .-'.•'n•�'.t.•.lei;•,� Y "J 'L. �.L`. aq' 'l.. y.' r✓ ti'"y`.. .'i.v �{y',tl.�ve �YSMk c�h�,",�v.=�f•e* •� �1,1"'{ p�$`�i'k°)":•....�-�iyf�
N. �' n..�2 k. .�- N_ ,..,4�� 1?fj: .#�.• ..f' ��-7i•. eJr 7 - k 1..'.'.�,*'^i., G,d :SM .p�`TY
•
ya`..r;+h`�'Y +a��y',:. r as" v� +:••$�' "wi ,w. 'Lt,.• �.45 .t .�'F u• •43'. �A3,'v"�.'$$� '�y �p;�--,3., 'd"J
.3.�.��•-p t��'i} �¢1't•..�''fv1:'�. �� ` ' y„r °�?.�.
..p:,�" r- d .#-`:+�c.. �%t:=d;� - is.tr,�xi, .r.°.��"r{ ;syE�," .4l', _ •r� �r�.• a � � � '�• -,.��'' ,r. :,� ..� !•�?••�;. r.
II �, •.Sft*, � 3, ,v,,; �,k' :...,,u,,.3 ,'� .� ��: ,,}r r„ •.,� -..�-•:a: +?' -..� ,�.' �°�',+. � Z' i�.„�>; eJw•'?..�s:.s�.2�:-- >'.
•� l ��tl ��}� t•
I•/'♦.�,� �f..t ,yt "' .'�..>x. .Ie3.tk:.�>• eI d,��.vz..a,?'x._. !}a':. 1itk,a'r� � '�,,.4 rT' .,,���" :,:.,a � a!, '�•�+.r .mot �Sl. ��. "5;'4��'... �' :i
Y
.• r� ! _
r
— g
f
{{
r�
to a
� r r71, �
K ,
,
rt
}. jo .
�► IS 7
Rj
�l �; ,,Jv,
An
444
*. �•p .s i €� < f i V 1 r n i f �}�i i���+� i*x ��i�4 h�}}6
{ s
4 �
w
a
��� '�. eat�.� + 'a. ?! �` .•, r �y .r„ ,, t
s
-. �. �. ,... ter, � �rl' `� 'Is' '[ + ,,i' +1 ' s `"+a. � { t.e. ry. - Cw. � •$ a "� "4.
r
v `
t
r
. _ §. .. °'�4 %,,�,,�:. .,.'�;. +: ,� +F`a�' �; a _ ♦i s"^'s�R
i y„
`. joy, '
St tl'
n i 'a►P ` y�' ' ;* �C`'.r k t«�v ,', + JC t 'rr f s ;x� A',
Y I
(�ra
��� C4 .. „. �••� }lief, `,���'r •..x�,r1^�.s!`i. r3. � P* .� • •�btr'p«fie* r
--�.,;., �... `. �.�� S,i{i�v 11��. r-" �,,xt�. 4 •' t ���4�}�+ ��,�� ^'�''a!t�*s, �.�. 3" ,y%:
,
Alp
44
� '���`.�",. :`3.=..tTxs Ei•'"' �'iTa.'�`',�"^^i�+Y>a. } r y' �� + V �S� � `s�j �,:,4',�,.•-r'.� W 'Nry � F y'1"""° �,ps,�5.;.
-' ,� i
�� .t-''�y. s, 1'y '0 '3 r� t p+ 1 "fin 7.�`{'S,•.4.s y}jA' i _�r 0,��,*•'4c' ,t�..�,
-t-i`'p' �:f +ja•` .v' ".y�F"yt''ti; '}S�'. i �ixa .wri, n 'rp , yi�"� yT Ar�, 7*► ,f`, �fCY .,.., - t'x .
� s d a-"t, � *tt•-3i� a`• •. °#szs � �3�,,,[ il.'Fr. �`ai';� i•;•x "S C,
o,. �.- art' '�•'`8, .,�.*' .���. ���".�.d. ��rs'�''''`�x'.,!f y�µ"�C..�i
.r ,?, t• �+,.,6 ""at ,j�tips' �` t` ,` iy �•...+WE r+aa'. rx"y '" .. `•."A' '.Cl• ' j +� sro_ "�`',r• +'
'► ,.[ k fi,4•.' � ",t?"}'_s T-.� 4 ,. r.s. ! ".,,
s v '`� x' -,� x' t{i�x,T s ��LL, .f• , �_ (`*t1c• �'1asC3 r4 �,,+t
• i
•! sue' t. +tit"�„''ks• i 'i#fix. *`� 55,,j-.•� ,,�..�`r*�7z1�,a,,`�•.� "..w "4R •c -.,*+•�" y:. �e'r 4. !s`7t=�
��`•� � 't.�x its. P ` :yt+ �`�a � :. <'�`°+" �;';
d' � .x�:��*s nC✓s�;:'tt�''}€'��i�� u, i.'. � r -"' a d,r '� x`t`���a��� ..ham ", � � �� �r��� y�r
.''�+.,•r�� +��.� �,'° _�z� x�"�z' 'fit � of -,1Px y , cry !yj '� f„t °f�j�' .-r ' q°: N '�t
i � .�t�:'�; } �.�,t ,� a � �'�.,;, � �•, x'�. .�. �2 � �+'y,'r�.�-"Tli�n � tt.r.y` .-=
t' `4� '4• r �" i- } yrr rr " `E xr ! •+j ' �
7,1
TIWI
':,�'C.� •'1-�$
� , W"Ix^ F,°',Kd�
99ss' t �d...�:`4 ,^'yc �,
-3Ms �' R'w"Y.. tl '.»i � � ' a' i, �1 "G +'«=�•
�aly.°`�;�;�L� ®�j�?1�." 4; ����';� -d' �lJ" �[M �7..�x' a ��. , �' 4.. � �• ��
vi
4
i-iig A og r
Ul
�y}j;� �i� '�R4��—•�•'x. +*•..`�4�r��� �'a".r ,� ter,°4�, -� ,a� X.r, y �'��a'
IZ
uW
may,.)�„'�i '.� __ ''f •� � '�" .. '.
'A
' �•� Ate':t,-�� •�- �rii��� � � �•, � Is...i. ,f'I ��
W
t
< 1
fir
ipi•r� i1-��*t'' .r i �,�y�.• R"'+' tr i �d �,, tx t �'�rz
��a ��,•y.•K.i^,C' ,t; rW�+ re"v .r:. `,,..,� :: S•k�.t" +.� ;r$ m S ; �e.� `` '"t� r
•
p -
5` s x
m
.r �c
k �
L
v �g
Y
�o
w
f
Al
jr
- f.i#FAT a #
r41 � ` �
t,
'.
114
7 tr
"fill
y INLET COVER
m ,�
i
ro�
a�
rV,.
� T' `�-� 'ky f• hut. a g M �fV„ 3
�3� d 'k ,.;x� a-r+ _ �t ,* � �. �* ,S �y s y �. # s,''_��g *'� -� sr•'.`_�� " $�,;,
m
� a
x �
� m
r
t
s
.c
-
x � r
x
�r
yL�y
�a x
DI SC / \/s \G E COVE
sk
! f f
4
� r
a,
a
x
i
MICHELE CUD'ILO, P.E.
Cons u:Itiing Structural Engineer
123 Cottonwood Lane•Centervi lie,`Massachusetts 02632-1979,• (508).737-8521: mcudilo@comcast.net ,>
October 16,2019
Mr.Thomas McKean, Board'of Health Agent
Toyvn of Barnstable
200 Main St,
Hyannis,MA 02501
RE: A"UILTINSPEOON
121 BETH LN.,Hyannis,MA
.Dear Mr. McKean,
Please be advised that the above captioned project has been inspected this date to review septic components,and then to
review proximity to the as-built bump-out..
The bump-out has a monolithic slab foundation construction. The.shallow sides.measure a.total of 20"from.top of
concrete to bottom of concrete. The embedment in the ground is.4". Therefore;the impact of the loaded corner of the .
gable end to the septic tank below has'adequate separation to not structurally affect the septic tank.
This office has.inspected the as-built bump-out proximity to the septic tank,and finds the construction adequate.
I trust that the above addresses your needs at the present time. Should you have any question on the above,,
please do not hesitate to call.
h
Si,ncerelr, _
Michele Cudilo,P is cy
/2019.327
GUOtt-O . �
SaUCYu�iAi. �,
Nn 347740 .�
ISI
,,F€SS10NNL.c�
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
'�1M ,•° Ilton Batista
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms on the *6
computer,use 1. Inspector:`
only the tab key
to move our
y Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
tQ P.O.Box 763
Company Address
Centerville Ma. 02632
r�"07 City/Town State Zip Code
(508)428-4028 S14454
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-t
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system: =,
4
® Passes "❑ Conditionally Passes ❑ Falls -,
❑ Needs Further Evaluation by the Local Approving Authority ;
6/11/2010 rn
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 a Title 5 Official Inspe lion Form:Subsurface Sewage Di osal System•P ge 1
Y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M Ilton Batista
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Ilton Batista
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (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.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5, Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M Ilton Batista
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) 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 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.
d
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M Ilton Batista
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. Cityrrown State Zip Code 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.
15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M Ilton Batista
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. CityTTown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
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
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Ilton Batista
'M
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d NA
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
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? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M Ilton Batista
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
-
every page. Cityfrown 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
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M Ilton Batista
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
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.):
Joints appear tight.No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
2'
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: 1000 gallon
Sludge depth: 511
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M Ilton Batista
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
27"
Scum thickness
3"
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
7" `
How were dimensions determined? 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.):
Pump tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09108 Title 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
Ilton Batista
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
__
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M Ilton Batista
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. Cityrrown 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 No
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 Ievel.Box has one outlet Iateral.No evidence of solids carryover.No evidence of leakage.
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M Ilton Batista
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 5-Infiltrators.
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.No signs of hydraulic failure.Leaching was dry at time of inspection.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Ilton Batista
'M
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
t5ins•09108 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
Ilton Batista
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
d
2.
3�
A , l
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M Ilton Batista
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of leaching 40'
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:
As-Built
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well data.USED:Technical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Ilton Batista
'M
Property Address
121 Beth Lane
Owner Owner's Name
information is required for Hyannis Ma. 02601 6/11/2010
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official, Inspection Fora
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
121 Beth Ln
Property Address
Mon Batista
Owner Owner's Name k
information is Hyannis MA 02601 3-17-10
required for y _ -
every page. City/Town State k Zip Code Date of Inspection y„
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.
A. General Information ; '
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
"
E. Falmouth MA• 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
LW
--i B. Certification
ca
YN
Z. I certify&that l 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
C:) was performed based on my training and experience in the proper function and maintenance of on site.. '
sewagg,disposal systems. I am a DEP approved system,inspector pursuant to Section 15.340 of .
- . Title O'CMR 15.000).The system:
asses '' ❑y Conditionally Passes ❑ Fails
❑ Needs Further Evalu ion by the Local Approving Authority
3-20-10
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or,
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the...
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the.approving authority. ,
****This report only.describes conditions at the time of inspection and under the conditions of use 13
at that time.This inspection does not address how the system will perform in the future under
the same or'different conditions of use. . y,•� .
Z4
t5insp official document•03/08 ` Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 _
r
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Beth Ln
Property Address
Ilton Batista
Owner Owner's Name
information is required for Hyannis MA 02601 3-17-10
__
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no si n of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND)in the ❑ for the following statements. If"not
determined,"please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old isavailable.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
121 Beth Ln
Property Address
Ilton Batista
Owner Owner's Name °
information is required for Hyannis MA 02601 3-17-10
every page. City/Town State Zip Code Date of Inspection i
B. Certification(cont.) -
B) System Conditionally Passes (cont:):
❑ distribution box is leveled or replaced:
f
ND Explain: _.
5
❑ The system required pumping more than 4 times a year due to broke'nj or obstructed pipe(s). The
system will pass'inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain: x
C) Further Evaluation is Required by the Board of Health:
R. Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to-protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)•that the system is not functioning in,a manner which will protect public health,
safety.and the environment:
❑ Cesspool or privy is,within 50 feet of a surface water r
❑ Cesspool or privy isFwithin 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and,Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
'The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet.of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply: ;
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c,M 121 Beth Ln
Property Address
Ilton Batista
Owner Owner's Name
information is required for Hyannis MA 02601 3-17-10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D System Failure Criteria Applicable to All Systems:
Y PP Y
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6° below invert or available volume is less
than '/ day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts ', .
W Title 5 Off icialInspe,ction f=orrn
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ^' z
121 Beth Ln
Property Address
" Ilton Batista
Owner Owner's Name
information is
required for Hyannis • MA 02601 3-17-10
every page. City/Town - State Zip Code Date of Inspection {
9
.. a.,' r .•...,.. .._..
B. Certification (cont.)
D) , System Failure'Criteria Applicable to All Systems (cont.):.
a Yes No
❑:. ®,,, ;, Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ 11 '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
R of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
L provided that no other failure criteria are triggered.A copy of the analysis
" } and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
•.. 10,000gpd.` "
The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be.
r necessary to correct the failure.
E) La-rge`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 barge systems, you must indicate either"yes" or"no"to each of the following,'in addition to-the
questions in Section D.
$ y Yes No
the system is within 400,feet of a surface drinking water supply
EJ, _.❑ ' ttie 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
ET El
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 o
regional office of the Department.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 121 Beth Ln
Property Address
Ilton Batista
Owner Owner's Name
information is required for Hyannis MA 02601 3-17-10
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees material of construction,
,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Beth Ln '
Property Address
Ilton Batista -
Owner Owner's-Name
information is Hyannis MA 02601-, 3-17A 0..,
required for Y
every page. City/.Town State Zip Code Date of Inspection
D.System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330
0
Number of current residents;
Does residence have a garbage grinder? ❑ Yes ® No
Islaundry on a separate sewage system? [if yes separate inspection required], 1 ❑ Yes ® No
Lau`nd'lr system inspected? "r ❑' Yes ®' No
t
Seasonal use?, ❑ Yes ❑ No
Water meter readings, if available last.2 ears usa e d 300gpd/2yrs
Sump pump? J ❑ Yes ® No
Last date of occupancy: f� 2-10 Date
Commercial/Industrial Flow Conditions:'
Type of Establishment:
Design flow(based on 310 CM 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ . No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5insp official document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Beth Ln
Property Address
Ilton Batista
Owner Owner's Name
information is required for Hyannis MA 02601 3-17-10
every page. City/Town State Zip Code Date of Inspection
D. System information (cont.)
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other (describe):
Approximate age of all components, date installed (if known) and source of information:
2005
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 cf 16
I TM
A ,
Commonwealth•of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments
121 Beth Ln
Property Address
Ilton Batista
Owner Owner's Name
information is
required for
Hyannis MA 02601 ' 3-17-10.
every page. City/Towne .,, state Zip Code Date of Inspection.
D. System Information (cont.)
Building Sewei,(locate'on site plan): .
+Depth below grade: 24"feet
Material of construction:
❑ cast iron 0 40 PVC ❑ other (explain):
Distance from private water supply well or.suction line: feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal :. ❑fiberglass ❑ polyethylene,"
❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--^------------------ -- - ---- ------- ------------------------------------
Dimensions: 1000 gal
Sludge depth: 16
_. 16"
Distance,from top of sludge to bottom of,outlet tee or baffle
Scum thickness 4.,
`j
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
13"
How were dimensions determined? Tape
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 121 Beth Ln
Property Address
Ilton Batista
Owner Owner's Name
information is required for Hyannis MA 02601 3-17-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
t5lnsp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts r
Title 5 Official Inspection F&M
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 121 Beth Ln ,
'd
Property Address v
Ilton Batista r
Owner Owner's Name
information is
required for Hyannis MA 02601 3-17-10
every page. City/Town . ,;�, State Zip Code Date of Inspection=
D. System Information (cont.)
Tight or Holding Tank(cont.) :
Dimensions:
Capacity: ,
gallons
Design Flow: - . 4,•., I>. ' '� 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.): s. '
*Attach copy of.current pumping contract(required). Is copy attached? ❑ Yes °❑ No
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.):
Good condition with water at working'le
Pump Chamber(locate on site plan)_
Pumps in working order: ❑ Yes- ❑ No
Alarms in wor6g,order: ❑ Yes • ❑ No
C
t5insp official document•03/08, - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�b 121 Beth Ln
Property Address
Ilton Batista
Owner Owner's Name
information is required for Hyannis MA 02601 3-17-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
4
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 5-Infiltrators
El leaching galleries number:
9
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Infiltrators in good condition with no sig9_9f back-up into d-box or surrounding stoned
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments .
121 Beth Ln
Property Address •r: c
Ilton Batista
Owner, Owner's Name
information is
required for Hyannis r MA 62601 3-17-101, = '
every page. City/Town State Zip Code Date of Inspection ,
D. System Information (cost.)' ,
. .,Cesspools (cesspool,must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth —top;of'liquid to.inlet invert r „
Depth of solids layer
R Depth of scum layer
Dimensions of cesspool a ,
Materials of,construction
Indi cation'of groundwater inflow ❑ Yes *.. ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc:):
Privy(locate,on site plan)`.
Materials of construction:
Dimensions ,~
Depth of solids
Comments (note condition`of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp official document•03/08 Title 5 Official Inspecbon Form:Subsurface Sewage Disposal System•Page 13 ofk15
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
121 Beth Ln
Property Address
Ilton Batista
Owner Owner's Name
information is required for Hyannis MA 02601 3-17-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
aCq,G
' � d
li -F_
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
f
Commonwealth of Massachusetts a
Title '5 Official `;Inspection Fo-rm,
o Subsurface Sewage Disposal!System Form -,:N.ot,for Voluntary Assessments "
„
121 Beth Ln
" Property Address
Ilton'Batista ..
Owner Owner's Name
information is 'Hyannis MA 02601" 3-17-10
required for Y
every page. City/Town State ,Zip Code Date of Inspection
D. System Information (cont)
Site Exam: -
EJ Check Slope t
❑ Surface water '
G
❑ Check cellar .
.. - .,fin•. ..
..Shallow..wells
W.
Estimated depth.to high'groundwater' _ 12'
feet
Please indicate all methods used to determine the high groundwater elevation.'..' a
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 Boardiof Health explain.,
Checked with,local excavators, installers- (attach documentation)
. ❑ Accessed US.GS database.-explain`.
You must describe hovi you established the highPgroundywater elevation:
Original design;plans shows no groundwater,at 12'.
,
t5insp official document•03/08 _ " 'Title 5 Official Inspection Form:Subsurface Sewage_Disposal System•Page 15 of 15.
.d . :
TOWN OF BAR.NSTABLE
LOCA'17.QN / Q e� �o . SEWAGE # I
VILLAGE T7 �'`�I�'1 S ASSESSOR'S MAY&LOT
_INS'TALLER'S NAME&PHONEyNO-
SEPTIC TANK CAPACITY
x/o X
LEACM40-FAC111TY:(4TC) f - s (siw) /
No.of BmRooms 3
JaUU DER OR OWNER
PERMITDATB: COIvB'LIANCE HATE:
Separation Distance Between the:
Maximum Adjusted,Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply-Well and Leading Facility (If any wells exist
on site or vAthin 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 30(t feet leaching facility) / feet
Furnished by °u/v► / ��/�
p
� c5rN
+,} .'41111\
TOWN OF BA.RNSTABLE
LOCATION 19/ 3-e cr/7 e- SEWAGE #
VTUJ AGE nn 5 ASSESSOR'S MAP & LOT a`7oZ ~-16 K
9J T O r T ER2S AT AX��N0. / m-t- A e to C/J
SEPTIC TANK CAPACITY
b�
LEACHING FACIL=: (type) � (size)
NO.OF BEDROOMS 3 ��rr
BBER-AR OWNER r e hit d e5
PERMIT DATE: Q,WPLIANCE DATE: 5
Separation Distance Between the: .�
Maximum Adjusted Groundwater Table to @,Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
j on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
_ TOWN OF BARNSTABLE i
LOCATION I� 7w, N \ SEWAGE # -
V. .LAGE -� S ESSOR'S MAP &LOT
` -PISTALLER'S'NAME&PHONE NO. d �
SEPTIC TANK CAPA.CTTY
LEACHING FACILITY: (type)II.-C _; "A (size) G'* �C l
NO.OF BEDROOMS -
BUILDER OR'OWNER
-PERMITDATE: �" ��+6 S -COMPLIANCE DATE:
Separation Distance Between the;
f Maximum Adjusted Groundwater Table afid Bottom ofLeaching Facility r r t^T P Feet
Private Water-Supply Welland Leaching Facility (If any wells exist }.
on site or within 200 feet of leaching facility) Y -fir'' Feet
Edge of Wetland`and.Lea'cl ing Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
�'�
ns
1^^
b"
C A
� � � n
I�
- - �
� .�
� w _
. �
� �
I r
��
i i
6
• E � � ,.
No. Ud � � _ Fee /Gd
• THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .(
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpplication for Digozal *pgtem Cutt!gtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) El Complete System [�Udividual Components
Location Address or Lot No. Owner's
Name,Address and Tel.No.
Assessor's Map/Parcel 7-7-1-1_1�� ���eS
Install Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
-P.a -�40 S ��..��s I�`o • �� 2� lr.
Type of Building: � r -7'7 s Sa 6
Dwelling No.of Bedrooms P�Lot Size sq.ft. Garbage Grinder( )
Other Type of Building / No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow / �(� gallons per day. Calculated daily flow �-Z—?�. gallons.
Plan,Date — Number of sheets Revision Date
Title er,
Size of Septic Tank Type of S.A.S.
Description of Soil 7 IoX3� �
1 3r)
Nature of Repairs or Alterations(Answer when applicable) fT_
Date last inspected: m
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title.5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has Board f ealth.
Signed Date `d
Application Approved by Date " /CI `G
Application Disapproved for the following reasons
Permit No. Z2y s_-- Date Issued
No. U8S 3
• �k ;� , ,. 4 ei'� Fee
TH Entered in computer:
MMONWEALTH OF MASSA�TS ram'
Yes
PUBL C HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Application for ;Di!6pogal *pgtem CCongtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade,(\.►Abandon( ) []Complete,Systemidiyidual Components
y Location Addre 1 Owner's Name,Address and Tel.No.
Assesso'c's-Map/Parcel ��'L!� e�Ze-S
AT Installe ' Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
1 .t U [O�Lv%_vk� SI Imo'4) •- {
Ty Pe of Building: p�j Q r 7 7'9 6
x Dwelling No.of Bedrooms_5 1 e Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures "
Design Flow — , 2'2.� gallons pet day. Calculated daily flow ' , gallons.
Plan Date~�°"7 1� �n�` 'i 'Number of sheets _� Revision Date v
,Title r )
Size of Septic Tank rir Type of S.A.S. 14 C,
Description of Soil; Z p v1 j0 X37 xrs
u b3�
Nature of Repairs or Alterations.(Answer when applicable)
Date last inspected:
Agreement:
v The undersigned agrees to ensure the cot�squction and maintenance of the afore described on-site sewage.disposal system
in accordance'with the provisions of Title 5 o4he Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has bP=Lia&ued y this Board of Health.
Signed f Date —� � `�
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 2c)(J 5�:- SR( Date Issued -7 ' 67- OY
-------------- ------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded
Abandoned( )by v _
at 'i has been constructed in accordance
with the prover 'o s f Title 5 and the for Disposal System Constructi n Permit No.?0o�-9?6 dated 7-15-05'
Installer [� r'� Designer
The issuance of this permit sh 1 not construed as a guarantee that e syste 1 u tion as designed.
Date `� Y 5 Insp ctor
------ r---------- — ------ --
No. Fee DtI,S - 3h �UG
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mizponl *p!5tem Con5truction Permit
Permission is hereby granted to Construct( )Re air( )Upgrade
System located at .,-P
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this ermit.
Date: Approved by c _
9/16/03
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems. Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
_ way ;,",,,hereby certify that the engineered plan signed by me
dated 13 aJ concerning the property located at
1.01\ ` ram . L(10 h1�C1�iS meets all of the
following criteria:
• This failed system is connected to a residential dwelling only. There.are.no.commercial or
business.uses associated'with the.dwelling. .
• The soil is.classified;as.CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or may conduct deep
m test holes and percolation tests at the site without a health agent present.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.•
• The bottom of the proposed leaching facility will be located no less than five feet above the
M maximum adjusted groundwater table elevation. [Adjust the groundwater table using the.
Frimptor method when applicable]
Please complete the following:
t `
A) Top of Ground Surface Elevation(using GIS information) b
B) G.W.Elevation _ +adjustment for high G.W. _
'h
DIFFERENCE BETWEEN A and B p?a , . d
SIGNED : DATE:
NOTICE a
Based upon the above information-, a repair permit will be issued for bedrooms
maximum.. No additional bedrooms are authorized in the future without engineered septic system
plans.
M
gASepdc\percexemp.doc
z
Town of Barnstable
Regulatory Services
Thomas F. Geiler, Director
k BARNSTABLE,
9� 1639. $ Public Health Division
�ED �A Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date:
Designer: Shay Environmental Services, Inc. Installer:
Address: P.O. Box 627 Address: 7 WT)Nua 5-
_East Falmouth, MA 02536
On was issued a permit to install a
(d te) (installer)
septic system at tve locch,5 based on a design drawn by .
(address)
Shay Environmental Services lnc. dated
(designer)
1,6 I certify that the septic system referenced above was installed substantially according to
the design, which may.include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e'
greater than 10' lateral relocation of the SAS or any vertical relocation of any component .
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
S�"OF UA,7
S
CARMEN
nstaller's q1 a ure) E.
SHAY
No. '1181
�p a
FGISTf-
SA.NITAR\P�
'--(Designer's Signature) (Affix DegilRIMTTStamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
R OF THE A
Town of Barnstable
* BARNSTABLE, * Regulatory Services
9 MASS. g a J
1639• �
Thomas F. Geiler, Director
prFD MAr
Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
July 19, 2005
Mr Michael Mendes
121 Beth Lane
Hyannis, MA 02601
NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V.
The septic system owned by you located at 121 Beth Lane, Hyannis,MA was inspected on
July lst, 2005 by Matthew L. Chilas, a certified septic inspector for the State of Massachusetts.
The inspection of your septic system showed that your system has "Failed"under
the'guidelines of 1995 TITLE 5 (310 CMR 15.00)DUE TO THE FOLLOWING: .
System in total hydraulic failure at time of inspection.
You have two years from the date of the system inspection to bring the system into compliance.
If there are any questions about this reminder,please feel free to contact the Barnstable Health
Department.
BARNSTABLE H TH DEPARTMENT
.7`1 0-S
COMMONWEALTH OF /. MASSACHUS
EXECUTIVE OFFICE OF ENVIRONMENT
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARy ASS INIENTS
SUBSURFACE SEWAGE DISPOSAL SySUM FORM
. PART A
x CERTIFICATION
Property Address: ITI 4• lei, ,
4 owner's Names. ,nn+K�L N-Wdas _ -
Owner's Addresm SAi nE
Date of Inspection: -1-1 0!�-
Name of"IInspector.(please print)-tNA4 kw t , L N -JAS
Company Name: S AA C
Making Address: 4 or 44,h 1 n,.
°Teleptione Number. Q-ti,A q-j y7
CERTIFICATION STATEMENT
below that I have personally inspected the sewage disposal sync this address and that the information reported
true,acanate and complm as of the time of tlse inspection.7U inspection was performed based on my
training and cgmience in the proper 8laction and maw of on site sewage disposal systems,I an a DZP
approved system inspecaorpursuant to Section 15.340 of Tl8e S(310 CMR MOON The system;
r
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fab
Inspector's Signature: Date: I- •o
The system inspector shall submit a copy of this inspection report to the pppmving,4uthority�of Health or
DM within 30 days of completing this inspection,if the system is a shared
and the
gpd or greater,the inspector system or has a design Bow of 10,000
System owner shall submit the report to the appropriate regional office of the
DER The original should be seat to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Now and Ccmaients „
•rsT'bls 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 is the future under the same or diQerent
conditions of use.
Title 5 Inspection Form 6/152000 page 1
Page 2 of l l
r
OFFICIAL,INSPECTION FORM=NOT FOR VOLUNTARY ASSESSSAM4TS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. PART A
CERTIFICATION(continued) '
property Address: I'Z,L_f3p I ne
nrN i S
owner. M,Ise M&Q f as
Dab of Inspection:]- -c
Inspection Summary: Cheek AJWX or E/ALWAYS complete aD of Section D
A. System Passa:
4 I hmnot found any information which indicates that any of the failure criteria described in 310 CAat
13.303 or in 310 CMR 15.304 exist.Any failure criteria not evalueW are indicated below.
Comments:
IL System Conditionally Passes:
N4i One or more system components as described in the Pass"section need to be replaced or
repaired,The system,upon completion of the.replacement or repair.as approved'by the Hoard of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.If.`dot determined"please
The septic tank is metal and over 20 years old*or the septic tank(whedw metal or not)is structtnDy
unsound,.exhu'bits,substantial won or meson or tank failttro is imminent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Hoard of Health.
•A metal septic tank wM pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND eacplaia:
Observation of sewage backup or break out or higbt static water level Lin the distribution boot due to broken or
obsuuctcd pipes)or due to s broken,settled or mums dim box.System will pass inspection if(with
approval of Hoard of Health):
broken pipe(s)an ieplaad .
obstrttcthan braved
distri ndon boa[is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obsumaed p4*s�The system will
pass inspection if(with approval of the Hoard of Healthk
broken pipe(s)are replaced
obstruction is removed
ND explain:
w Page 3 of 11
OFMCIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
,> CERTIFICATION(coatimud)
Property Address: ill I N,
A1VM't
Owner: i kl- Montt
Daft of Inspection: 1-1-a 1- _
G Farther Evaluation is Required by the Hoard of Health:
Conditions exist which require evaluation by is the Board of Haft is order to determine if the sy:aem
failing to protect public health,satiety or the ewAronmeat.
1. System will pass unless Board o(Health determines in accordance with 310CMR 1
system is not lhnetioning m a maaper which WE protect public health, s` (1�)that the
safety and the envirounuatit
1 Cesspool or privy is within So feat of a siaSce avatar
Ia• _ Cesspool or privy is within SO teat of a bonderiog vagetsted wetland or a salt marsh
;. System will fail=Jess the Board of Haft(and Public Water Supplier,If any)determines that the
system b lhaetioning in a manner that protects the public health,safety and environment:
. _ The system has a septic tack and soil .
surface water Epp sbso�ptian sYg(SAS)and the SAS is within 100 feet of a
or Y to a sine avatar supply.
4 17te system has a septic tN*sad SAS and the SA3 is within a zau 1 of a
r public water supply.
The rystem has a septic tack and SAS and the SAS is within Sect ofa private water supply well
The system has a septic tank and SAS and the SAS is less than 100 fat but SO hater more ftm a
p<ivate wamr,supply well••.'Method used to detmmn
•'?his system passes if the well watt analysis.PaSirmed at aDEP certified
bacteria and volatile arMk compounds Wkatet that the well is tires S+om aY�for coheM
the presence of ammonia nitrogen and niaate Pollution from that that
n ty and
failune criteria are triggered;A of the t�'oSco is�to or lest than S ppm,provided that no other
copy analysis mart be attached to this faznn.
3. Other.
Page 4 of l l
r
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DEPOSAL SYSTEM INSPECTION FORM
PART A.
CER7MCATION(continued)
Property Address:
owner:
Date of Iaspeetlon: -—LOS
D. System Failure Criteria applicable to sII systems: ,
You uL
ja indicate"yee or"no"to each of the following for gginspecdom
Yes No
i/ Backup of sewage Uwdmft or system component due to overloaded or clogged SAS or cesspool
—' Discbsrge err l - HI g of effiueat to the smf=of the ground or sudkee waters due to sn overloaded or
-- clogged SAS or cesspool
Static liquid level in the distribution boat above outlet invest due to an overloaded or clogged SAS or
cesspool
✓ _ Liquid depth in cesspool is less than C below invert or available volume is less than K day Bow
_ ✓ Required pumping more than 4 times in the he yeas= due to clogged or obstructed p4*sj Number
y AW portion theof SA4 cesspool or privy is below high ground water elevation.
Any pardon of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water .
✓ Any portion of a cesspool or privy is within a Zane 1 of a public well
Je, Any portion of a cesspool or privy is within 30 fed of a private water supply well.
✓ Any portion of a cesspool or privy is less than.100 feet but greater than 50 feet Dore a private water
supply well with no acceptable water quality aaslysis.(This system passes N the wen water malysis,
peribrmed at a DEP earthed laboratogr,for eoiltbrs bacteria and_volatile organk,eompoemde
Indicates that the well is fret!!•oar pollution from that heWty and the presence of ammoals
nitrogen and nitrate nitrogen Is equal to or led than SpM provided that no other failure criteria
an it ggescd.A Dopy of the anal mast be attached to this form.)
ws (Yes/No)Ime`'systen ha I have determined that one or more of tie above failure criteria exist as
described in 310 CMR 13.303,'tba�efor+e the system fans.The system owner should contact the Hoard of
Health to determine what will be necessary to correct the failure.
& L ulp Systems: �h..
To be considered a large system the system must serve a facinty with a design now of 10,000 gpd to 15,000
f -
You must indicate either or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
— — the system is within 400 fed of a surface drinidag water supply
the system is within 200 fed of a tributary to a surface drh ing water supply
— — the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"�►es"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 3I0 CUR
15.304.The system owner should contact the appropriate regional office of the Department.
1
r
1` page 3 of 11
- _ OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOILNI
PART B
CHECXLIST
Property►Address: i Z i v 1 A, W .
Owner. ryki
Dab of Inspections
Check if the following have been done.You most indicate myean or am.as to each of the lrollo
wi
Yea No
— .—^ PumPleg Formation was provided by the owaa,occupant,or Board of Heahh
Was nay of the system component pad out in the previova two weeb?
a
v
_ _. Has the system received normal flows In the previous two week period?'..
{ Hive large volumes of water been lutroduceti to the system recently or as part of this inspection?
_ Were as built plans ofthe system obtained and cmminge
(If they wero not available Dote as N/A)
Was the facility ar dwelling inspected ibr slgas of sewage back up?
� Was the site Inspected for signs of break Out? ..
V _ Were all
system components,excluding the SAS,looted on site?
_ Were the septic leek manholes Uncovered.
of the baffles or tees,material of coastiuction,diauna;mod'and the interior of the tank inspected for the condition
ans,depth of liquid,depth of sludge and depth of scoot?
v Was the
maiatenaac of s*owner(andrf diffQ+Ow from o�)provided with information on the proper
sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on;
Yen F.nisting information.For example,a plan at the Board of Health.
v` Determined in the field(if any of the faili m criteria related to Part C is at i
is unacceptable)[310 C AR 133 ssue
0Z(3xb)l aPp=(imation of distance,
}
t
page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSbMNTS
SUBSURFACE SEWAG$:DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Propaq Address: iIt Itj
Owns: i"` Ic e MtN S
Dab of Inspection,: -1"i-on,
>h-Low coNDrrlorls
RESIDENTIAL '
Number of bedrooms(design):1— xmnber of bedrooms(acmaW. 3
DESIGN flow based oe310 CbR 13203(for le: 110 x 0 of bedrooms): t• a
Number of current residents: 2 .
Does residence bae a garbage gindw(yes or no)s�
b laundry one se wM.sewage system(yes on,no):No (if yes separate inspection required]
Laundry"dem.iaspecfed(yes amok WO
seasonal use.(yea or nor ND
Water metes readings,if available(let?years usage(Spd)):
sip l=p(Ym x `0
Last date of occupancy:= 4
T�pofestiblis U81'RI4#AL l A
Design Sow(based on 310 CUR 13.203):
Basis of design Raw(sesW. 1,s,d3q t etc.Y•
Cinm,rap presentcyes ormx—
Indusodal waste holding tank present(yes or no):
Nan-sanitary waste discharged to the?idle S system On or no):
water metes readings if availabic _
LAN daft of occrrpmcy/nae:
. oT1�R(descnbex . .
f GENERAL INFORMATION
Pumping Records
source of iaformatian:Q-jr-ttr -
Was system pumped a:part of the inspection(yes or nor ro
If yes,volume pumped: gallons—How was quantity pumped determined?
Reasou fan,pumPhi
TYPE OF SYSTEM
_Septic tads,distribution boor,soil absorption system
—Single cesspool
_Ovallow cesspool
_Shared system(yes or no)(if M attach previous inspection records,if any)
_hmovadve/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained Avm system owner)
Tight tank —Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes of no): !'�
Pap 7 of l 1
. F
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
( SUBSURFACE SEWAGE DISPOSAL SYSTEM IIVSPECTION FORM
PART C
SYSTEM INFORMATION(cominued)
Property Address: `2 I nv..
Owner. rt1tN d o.
Date of Iaspecdos: -�-oK
BUMDUM SEWER(locate on site plea)
Depth below grade: 1.7,
Materials of consmuctiow-_cast Iran 40 PVC_other(ex h&j.*
atsa Dica from private water supply well or suction lice: .
Comments(on condition ofJoiab ventin&evidence of leakage.etc.):
Ak\--i N (rwA QgJA;ii A J c..M kA A nG i`n!So by
SEPTIC TAM✓(locate on site plea)
Depth below grade: r
Mau rial of cotisontctian: eoncrete_metal_fiberglass_„polyethylene
If tam is metal list age:_ b age confirmed by a Cerd&.ue of Compliance(yes or nO_,(attach a copy of
•: Dimensions. $Y S X f uv Vs 0' CUDIL frA L
Sludge deptb: •
Distance from top of�sludge to bottom o_f outlet tee or bade:
Scorn thicb1e= a 6
Distance tinm top of scum to top of outlet tee or battle: a Zl
Dlataace from botwm of scum to bottom of outlet tee or bate:
HOW were dimemiona determined: �g2 ��rda
Comments(on pumping recammendanons,bdet and outlet we or baffle condition.structru nl integrity,jiqUidlevels
as related to outlet invert,evidence of leakage.etc.):
S�Pi�c �n*rK cMbLA ,0 C:&-A sc 1,0JU L-C o/'car►AAr0f 1
GREASE TRAP:Ablocate on site plan)
Depth below grade:_
MatmialofcoastrucdOw._-concrete metal_fbaglass_Polyet!►Ytene other
(exPl"mr
Dimension: .
Scum ddck ness:
Distance ftm,top Of top of outlet tee err baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Cemsaeats(on pumping rrcoarmeadations,fiLk and outlet tee or bale condition.sm=uai integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
•
�• r'
PIPS of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM IKSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address 11
ANwi S
Owner. iy%i 4 n W.(,s
Date of Inspection: "I-t-os
TIGHT or HOLDING TANK: d6(tank must be pumped at time of inspectionVocate an site plan)
Depth below grade:
Material of construction: concrete metal- fiberglass_polyethylene 9thet(exp1810
Dimensions:
Capacity: Qallons
Design Flow: gallonsIday
Alarm present(yea or no):
Alarm level• Alarm in waridng order(yea or no):
Date of last pumping:
Comments(condition of alarm and float switches,eta.):
DISTRIBUTION BOX: a/ (if present must be opeaed)aocate on site plan)
Depth of liquid level above outlet haven: .'
Comments(note if box is level and distn'bntion to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
Q-QOX uj" ,Cver" bP �O 1 k kk-I J& i 10 W vdC g i't 4 P -h1 %L 6C I�� •
PUMP CHAMBER:.(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etck
" Page 9 of l l
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
/ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
`• PART C
SYSTEM INFORMATION(continued)
Property Address: t t3EA 10
Owner. (hJ ke Mery 3
Dab of Inspecdoa 'I-t-or
SOM ABSORPTION SYSTEM(SAS): y (locab on site plan,ezcavation not required)
If SAS not located explain why:
Typ
- pm.u t nber:—leschin
g ehambas.numbs;
leaching gallaies,number
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,mtmbet:
inaovativelaiternative system Typdaame of technology: ,
Comments(note condition of soil,signs of hydraulic failure,level of pondin&damp soil,condition of vegetado%
ate.
.W 'ZV off' Sfun�e feu i,Q( kUd . �,���� 1 � 4r_ .;✓ :I e l�"yet
CESSPOOLS:.N��(cesspool must be pumped as part ofinspectionxlocate on site plan)
Number and configuration:
Depth—top of liquid to hda invert:
Depth of solids Lye:
Depth of scum layer.
Dimensions of cesspoof:
Materials of construction:
Indication of gromhvuw iafiow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of pondin&condition of vegetation,etc.x
PRIVY: W 1A (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Commem(note condition ofsoA signs ofbydrm&e fa wr,level of pondin&coadidon of vegetation,etc k
I
r
Page 10 of 11 s
n
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAI.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: MI Gt44, ►tv..
4 ANO;s
Owner.fin;kA W\"16
Date of Inspection: 1 -10 K
SI1FTCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system inchtdiag ties to at least two permanent refaence landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply ehters the budding. .
�J
� 3
L to Z. 6,4.' Z.-3- `
4
--------------
Izl
page 11 of 11
. OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM[Ti 1SPECTION FORM
PART C
SYSTEM INFORMATION(condnued) .
property Address: 1 Z 1
Owner:f 44-1- r^^•&1'W& -
Date of Inspection:
STrS EXAM
Slope
Surface water
Check cellar
Shallow wells .
EstimaW depth to ground water'?1 o feet
plem indicate(duWo all methods used to determine the high ground water elevation:
Obtained Som system design Plana on record-If check4 date of design plan reviewed:
T Observed site(fig prop�y/ohservador<hole within 130 feet of SAS) '
Checked with local Hoard of Installers-(attach doarme�ation) '
lAiM
Checked with local cw vators.
Accessed USGS database-explain:
YOU must be.how you established the high ground water elevation:
Q�MN 'Sim W, IJb S;1,0%
. ll
C7
LA'� ATION J SEWAGE PER NO.
., nv l ov 6 2 61
V11LAGE
INSTALL R'S NAME & ADDRESS
74
B U I'L D E R OR OWNER
rPo,S l A.a�
DATE PERMIT ISSUED C"—;21-77
DATE CO-M.PLIANCE. ISSUED �,,2y-77
L -�
r ) ��s Q
NO..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... .......OF...............................................................
Appliratiuu -fur Uiipugal Work.6 Towi#rurfiuu Vrrniff
Application is hereby'made for a Permit to Construct (V) or Repair ( ) an Individual Sewage Disposal
Syst at: -
C� L orLt kw
oca s2 �,,� s dress
....
. � C
°
Installer Address ��. 00
U Type of Building Size Lot...)___ ------------
-----Sq. feet
Dwelling—No. of Bedrooms............................................Expansion tti/c�( ) Garbage Grinder ( )
Other—Type of Building v--------------- No. of person ._s�� .V howers ( y} — Cafeteria ( )
Otherfixtures --------•-------•----•--•-----------•-------------------•------------U------------------------------------------------------------------------•-------
w Design Flow................................ gallons per person per day. Total daily flow----------3_4�---------------------gallon,.
WSeptic Tank—Liquid capacit. __.._,_____gallons Length---------------- Width--------........ Diameter----------.----- Deptli---.__ --------
Disposal Trench—No- -------------------- Width------------ -____ Total Length-------------------- Total leaching area.--_-.-.-----_.__---sq. ft.
Seepage Pit No.....I............. Diameter________ __ _o Depth below inlet.................... Total leaching area------------------sq. ft.
Z Other Distribution box (A Dosing tank ( )
~' Percolation Test Results Performed by -.---A_----- .............................................. Date--yk-07.1----._-___---_
1_ Test Pit No. 1----- .------minutes per inch Depth of "Pest Pit____________________ Depth to ground water...._-__--_.._.__..___.
t=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...--.---_-_:_-:--------
- --- --------------- ....
-----------------
0 Description of Soil--------0°' ' +1 ------On--- - �
w
---------------------------------------------------------------------------------------
Nature 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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss dhe board of health.
/
Signed. .-'-' .----. ---------•--•-----••-------•--------------•--•-
/ Date `1 7
Application Approved BY :..... -.'..-------'--------
Date
Application Disapproved for t 7.e following reasons---------------••---•---------------------------•-•------------------.•----------------------•----•--------------
...................................•------•------------------•------------------•----------------------••------------------•-----.........•---------------•------------------------.--------------------
Date
4.
Permit r!-,4 0. 7
---•---•-•--•----... Issued--------------------------------------------------------
Date
- I
THE COMMONWEALTH-OF MASSACHUSETTS
BOARD OF HEALTH
.......... . ._ --------------OF................................•---. ...........---.-------•--.----------•-----.------.
Appliratiun -for R_qv sal Works Tonstrnrtinn Vrrm t 1 I
,.
;A rh':ation is hereb made for a Permit to Construct ' or Repair an Individual Sewage" Disposal
PP Y� ( ) P ( ) a P
System at
44
-_ ----------Loc -G-t�_ -A . ...............
........f4�E
./ l or Lot o
1
-
`-
K
� �^•4���r � dress .
40
Installer Address
Type of Building Size Lot---- -- _`- -- ..__Sq. feet
Dwelling No. of Bedrooms____ Expansion ttic., g— __-_ p ( ) Garbage Grinder ( )
pa, Other—Type of :Building �.............. No. of person� --___�_.. ._._.___:_. howers
dWOther fixtures ------------------------------ --=-- - ------ -------------------v------------•-----••-•-----
.�-- --------------- ------
Design Flow_________________________•--_ // _-_ gallons per person per day. Total daily flow.......... .1__:✓......................gallons.
WSeptic 1 :nk—Liquid capacitA� gallons,. L�ngth................ Width_ __-_......_.. Diameter____-__ ------- Deptll_
x Dis osal..Trench—No.•--___--__ WidtTi`:. _._�_ ___- Total Length.,......... ......... Total leaching area-___________---_____s ft.
P.. g 9
Seepage Pit No .__/_-•--________ Diameters : Depth below inlet:...............:... Total leaching area______..___--__sq. ft.
Other Distribution box Ssi '
Z (l�►) Dosmg tank ( )
Percolation Test Results Performed by�� __-C1+�.45;!' `..................................... Date_/m_(i.1?..._-----__.__----
1 Test Pit No. 1----- -_...__minutes per inch Depth of "Pest Pit____________________ Depth to ground water..-__-_____-__----.
G4 Test Pit No. 2----------------minutes per inch Depth of 'Pest Pit--------------------- Depth to ground water_-.-_-____________.__...
------- •...---
O Description of Soil
x j x-
.__________.•---•___--_____ �--- ..................44* ""'•"`^" _ ""�'-'_..`.'_��-•___•----_ ---•-_._•___________________________________________•--_-•.---__ _ ---.
`d __.__ __ _.. _
r
V Nature 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 Article \I 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.
Signed ` `" .......�i--" -----------------------------•-----------------
-----Date
Application Approved BY---------- ----------��-----------------------------------------------------•-----------•------•-• --------- - -----------------
Date.
Application Disapproved for t ie following reasons:-------•--- -•••------------ -----------------•-----•-•-•------------------------•----•------------------------
--.....-•--••-••••-•------------•-•-•----•--•------..--•••-------------•--•-------••----•-•--•--•-------•-----•----•--•=-•--=--•=------------------------.----•-----------------•-------•-------------
Date
PermitNo. - r . --•--------•-----------•--------------- Issued.........................................................
Date
` M "'t .
TFE COMMONWEALTH OF MASSACHUSETTS rr
' e
,.. BOARD OF HEALTH
........ ...... .........O F......... ....
Yl w Trrtifiratie of T"Inmpliantr
THIS IS T,Q CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
-alle............................................. •--------------------
n taller
---- Ift-4----------- -----------
at ---•--... •. ---•--_--
has been installed in accordance,wrtli the provisions of icle XI of The State Sanitary Code as described,in the
application for Disposal Works Construction Permit No:___k_; ___•________ dated...____ _.___ .. .
: ' r
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.......................................................---••-•-••••......------. . Inspector................................ .....................................
THE COMMONWEALTH OF MASSACHUSETTS n
BOARD OF Hf 'ALTH
............. /�'�'C .........o F...... T 1�°..�.'.......
No._-•--,!......................... FEE ...........
nrk�Permission is hereby granted - tr�trtinit �rr�ti#. ,
r, :----
1'� - -- ----•---- ------------------------------------------------=.............
to Construct or Repair ( ) an Indi idual ewage Disposal Sys�grril���`�
atNo.-••••-••-•••••-4,#• -=-------i�1r _ _ _r r�l�G -- ----- ----- -----------------
,. +
as shown on the lication for Dis osal Works Construct'on e mrt.`N-- �' '� Dated._.._ ____
M1
-- - -------- --------- -
Board of Health
DATE...........
....................... --
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERSe
k
C6"i'M WFAI.T11
EA-1-I(TTIVE ( )FFICF, of ENV1H0N.N1LN,r,,
NTA1, VizoirnnON
DEPARTMENT OF EAVIRONME
B(ISIVN 1!A tr,,lo 1;3 7) 2i)2-.5500
71 RUDY CORE
Secirctary
..R(.'U) PACI.C1','.'-I'Tr DA�l Zl,13. S'F HRU S
oinnussioner
SUB(it, I?F M"I SfAVA(,!. [)ISP(.)SAL 1:Avi tNS.1-11-CTION FORM
PART
Property Address; L2 k -ziek'-X Cite- i3r 0kV.6 of Ov.,,,: Me wt nnc>n(1l1.Cj,-
-
Date of Insp e rtion: OkS it ('11iiurt
tiarne of lnvector:
I am a Df.P .11)p r o v I d I t I p I i r u,1111 1- S k c t I n I I I of tits" 5 [3 1 J CN i P 15.000)
party Narne: _4 -
Stalling Address: A...415ro,
Telephone Number:
CERTIFICATIC)N s rATF 1W.N I
certify tnat i !iave personally inspvcied the e\s—ae 61-,po,i- "YqVI'll 0I this at&e,.,s .nd that the information retuned belov. is true, accurate
and:complete as of the time of inspection. Tne ;nspv(tion sa. p(,riorined based (in my training and experience in the proper function unction and
,maintenance to on-sij(' No 1'. disposal 'Jil"
falls
-"o Inspector's Signature: Dale:
The System inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30) days of completing this
inslwclion, If the systern is a shared systern or has a deslf!n flow of 10.000 glicl or greater, the inspector and the system owner shall, submit
the reoort to the,appropriate regional office of the Departmen.t of Environmental Protection. The original should be sent to the system owner,
and copies sent to--the buyer, if j)(I(I (he ,tpprrn'�ng authority.
INSPECTION SUMMARY: Check A, B, C, or D.
A) SYS T" PASSES:
I have not found.any information which indicales that the sy,,v-tn violates any of the failure l;riteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indiratod bf-low.
COMMENTS:
G] SYSTEM CONDITIONALLY PASSF5:
One or more systern components as descril)rd in the "Conditional Pass ion need to be replaced or repaired. the system, upon
completwn of the replacement or renoir, as approved by the 60 Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND!. Desch asiS of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless owner or operator has provided the systern inspector with a copy of a Certificate of
1dl; in in
Compliance (attached) g that it)(.- tank was installed within twenty (20) years prior to the date of the insoection: or
the septic tank, whe or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
f,AutL i6s irnfnl The systern will pass inSWbOlon if the existing septic tank is replaced with a contorming sentic tank
as at,
J,Proiii�
prov ly the Board of H(.
t(rovis6d 04/25/9 Pogo 1 0! 10
�Ufi 11,1CL NE A(J DISPOSAL SYSIL•M I'\WFC*TION FORA
PAkf A
I k l Il IC.ANOW trnnt�nut(fi
Properiv Adcltt ,�:
ov.ner:
Date of In,-Pecilo.
BJ SYSIL,M CONDITIONALLY PASS0 (Ci?ntuxii'W
_ `C11'dk;t` 111(hlkil or bl'Virkurrt ,.)t nit;t,rn V'd vvcl in diNinhution Ill?\ +s (rut- tr, Urc ker, or w,,:ruC:ou
pint t> ur due to ;1 hiokPn, �cyi f(I disc ihuii(>n ho'k, lh(I scsicm l\ill pass in>p+,ctiun if :with approvai of Inca
or due to 'k bloken' �'�eil
q:uri of He.tlih). Des(, )r
c?I?s 'ction I,. rr nu>ti ti
isirihuliun hr)x i,, li odkl d or repla(od
iw �\••ie r(,,jwr('d twu)puie more lh;,n lour times a \e,ir dw., tf) I.-rukeri w obstructed pipcisi The syslem t+ul t its,
Inspcc on if f�%ith apprnvol ,,f the lloor.l of i1(�Althl:
brokt'n pfjw,,,J .iiv w;?13(,t'd
Cj FUkTHUR INALI.:AT ON IS REQUIR(A) lil Tfif ROAKI) OF I-KALIHt
Conditions e\,,t which require iurt.'+o( Cv,; t it Cn i!v the Board of :-lea in urdt:r to determine ii the sasteni is railing to orwect the
public he:;;;h• saie;y .end the (.-nvi:ijnmerit
1i 5YSTE.tit WiLI, PASS UNLESS 130ARD OF 11FALTH 1:)ET5ZW5hIAT THL• SYSTEM 15 NOT FUNCTIONING: IN A MANNER
tti►�rr►� t.r,t vkr'ltli SHF Pi F;; ;. Ili 4i At :,Nil, IF
Cesspuul or pnvv is r.i:hm 50 t;,et r): soliac.e water
Cesspool or Iinvy i5 within ;?O fCCt i a hrudering vegeloaed wellarid or a salt marsh.
:) SYS•IEM WILL FAIL UNLESS THE 110 .D OF HEALTH (AND PUBLIC 1WAlER SUPPLIER, IF APPROPRIATE? DETERMINES THAT
THE SYSTEM IS FUNCTIONING 1 A MANNER THAT PROTECTS THE PUBLIC: HEALTH AND SAFETY AND (HE
ENVIRONMENT.
The system has a optic tank and soil absorption system ;SAS) and the SAS is within 100 feet to a surface water supply or
�. tributary to a 5 ace water supply.
The system h a septic tank and soil absorption syslern and the SAS is within a Zone I of a public water supply well.
T•he system ias it septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The cyst has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private ater supply well, unless a well water analysis for colifonn bacteria and volatile organic compounds indicates that
iFe\ .11 is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
` les than 5 ppm. Method used to determine distance (approximation not valid).
I 3) OTHER
1(ravixed 04/25/97) Page 2 of 10
ms p0s.\i. LN S If�i IN"11K 110 IN I OR."i
PA R f A
Itimcmiwq it rit I I I tit,(J)
c,n pe
Date of Inspection:
L(
DJ SYSTFM FAIIS:
rm w \(I" .1', lij (," It iol tits. 1,111owil)Q:
V101aWl. one (,, !liore o! the Ioll(w.1ne. IjIlton, torl'i I, dolined In it() C'OR 1.5,303. 7i,v bas,s
!")r Ifii? oew,minanim „ idewitied Iw 1.ioj,d w 01004f L0 ' it,'j('jVCJ !o oewrrnine %Nnoi will he neces�,iry !o Cor(C.C1
5.1c k,.l 1) (,1 0 QW I I I 10 Ta(I I 1i\ (i I -V'-I"M (01 TI 00 1 Wf i Jue III an overloaded or dogged SAS or cesspool.
'Is( of pondirls! ot i,irluunt I(, !w Build' of the [;round or stirf,tce wate(s due to an overloaded or clogged j-\S (I,
!"vi( I quid level III the (J1_tiIfI0LJI10!I Ok 0WIVt invert clue to vn overloaded or clogged SAS or ces,,Dool
L (101d (14-1)111 In I I% 1(1ti han f," helow viveft of i1,iiittble volum(' I,. less than l,'2 day dow.
nf'( -6 IMInDing rp.,)rc -s III dw lost vvar NOT dLJV. 10..m I imt lolzgeu or obstructed picte-51.
Nurn"wr III tarn pulill IJ
n\ ;)L)rtinn I);th Soil Mhsorp:iun cesspool or f,rltt is below the hr,.h groundwater elevation
�m portion if a ces�jjool tir nrlvv 1� tti 10wi 1001 f(-el of j surl,ico water skjoplv or tr butai% to a surface water supply.
v portion of a or prr.,v is within :)o wet of a private w,iter supply well.
AI)v Portion of a Of ;M'A IS 1(-,s than 10() It-et [)ot frej1pr Jl)af) 50 feet from
a private WdWf SLn)p1t, .--li with no
d(.cvp;able A.ocr quaint 1i tho ',Y(.Il 11,1s 'wen. onalvzed to 1w accelill-Ible, attach copy of w(jl water onak-sis for
oliform b,vit'ria, vol ,1,1r orlynic f anil)on;,I nitrogen 'wrl nittale nitrogen.
El LARGE SYSILM IFAIL5.
You must incitc.ite either "Yes' or "No" to each of(Le ;,)Ilctwlng�
The following criteria apply to large 'y"Jeflim, in aclifition to the criteria above.
The ,-stem serves a facility with a design flow of 10,000 gpd or great Large System) and the system is a significant threat to
pui.)Ijc health and safety and the vnviionrnent because one or III of the following conditions exist:
Yes No
the system is within 400 feet of a surface rinking water Supply
the system is within 200 feet of a tr utary to a surface drinking water supply
the system is located in a ni gen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone 11 of a
public water supply well
The owner or operator of any such s, ern shal! brin,,, the system and facility into full compliance With the groundwater treatment program
requirements of 314 CNIR 5 00 art 6,00. Please consult the local regional office of the Department for further information.
11(revi.s*d 04/s5i97) page 3 of 10
'l,ElS;.:lifACE SEWAGE: DISPOSAL S151E1.1 INSPECiIOIv IOR.M
PAU B
Olt Ckl is I
Propeffy Addrc:.s: t
Owner: rW\e V\A on AQ
Date of In;pec;ion:
Chock it Nie rokow!11e have becil dodo l ct.t t:u.;,l ur.tr(ate viihvf Yos" or a .I> to o,u.h of lhr fo+lowuin
o
Pumping Inforcn.ltion was pmvl(lod by the ownly, Uc.(Ut>.Irtl, or Boos;( of Eieaith
None of the systf•cn (ontllncie+,is h,fv(, been uc;rf:;>ecJ fc>r ,u lt�,)St two w'e(•ks and the.system has been receiving normal
;low rates dunnill 0F,it prrv)d Lawv v(+lumrt w v Ater have not been IntroducPd into the system recently or
as part of lhts rn poction
built pl +ns hovk rrren ot;;ained ,-id examined, `.ole If ihev arc not atailjbh, with
he fatality or&v(!j:,ne v-is mspecic-d fnr S,iv , of svvdage o.Wr.k-up.
the ':Yslem dovk n,.it rt:rive non..,.,irw tiry or indust;i,,f %vage fin.,
he site was ut.pe led fur signs of h1vokout.
LI All system cur iptwents, c•v(luding Ow poll Absorption Sy:,tons hove tmen IUCJtcJ on the site. /
1C __ Th., ;,;c.�ie. {u.r�s; I`l(+ j•. r, Lid,.i";.(1 ,cr•L�'r'C� �6'•r�.,��A�'�f(+e�r�►� ��.�,
uariit's or wos, in,oc! ,; of It unsirw i,un. ,llllwfimaUllt, kivIjlh Ui ,iJ,lilJ, OCIA1 (+,f Sludge, deptr, w Scu,'r.
PLKe sale anti location of the Soil Absorption Syst(�m on the slto has been determined based on:
he fa(ility uv.ner land o((mmnls, ii difierent from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal S)'rlorn.
Existing information. Ex. Nit at 13 O hi,
Determined in the field Elf any of the iailure criteria rel,.ur•d to Pan C is at issue, approximation of distance is
unacceptable) 115,30213?(blj
1(zaviaed 04125/97) Page 4 of 10
DI-0,0S.-ki, SYSI I'M l',iSPK il-0\ 170K.Ni
S`rSi[•M INIORMA110N
Prnperty A(J(lr(-s,: 1:2 C 8e)YL L'a0tw
O%iinet: 1W1eAA6kAC,
Dale of inspection:
FLOW CONDITIONS
- O Number of t)(-Jrourns JA
-N u-Ti be r or cuirent residents.
Garbage grinder i-o:< or r1o): ffo
Laundry corinecied to 5vstern wvs or 11C 7,
Se- - ji use rues or no): PX 1 *3
:`rater mc-ter wao I ii,i"S, ,P-� dj:,):1 6.1"1
Sump Turn;, MIS of 1)
Last d3lf! (11 OC(Uncinc\1
Tvpc I,(
De-o(!1I ilow: galloils"(1av
(,rease trip preser)!: O-es or noj__
jn(1Uf.trwi Vi'aste Holding T:ink prnsvnt. r q ------
',4on-sjnii..3r\. waste tJischar�;erl to 010 i,Ilv \.�ww %i-s of
Water m.elcr reaoings, if w.-allahk zz
OTHER: (Describe!
List (late of o'..CU 11,'1C11:
G[NI-RAt VJORMATIOIN
PUMPING R!.CORDS and yurc LL11orm 114
.3 A C? &6 0001L
System pumps.-j s part oi inspe-lion: p 5 c r n
It YES, volurrlo i)Urnlx-d: alJons
Reason for pumping:
TYPE a SYSTEM
Septic tank/distribution box/,,oil ;ib„orphon wswm
Single (es%poul
Overilow cesspool
Privy
Shared system (yes or not (it yes, attach previoui ms4)ectiun records, if any)
I/A Technology etc. Copy of tip to (late contri)(.V
Other
APPROXIMATE AGE of all components, (late installed of known) and source of information: Ae
Sewage odor; dt-ti-i'ted when irrv.-ifw. it the .,I- lve,- ii, flo) IV6
I (rSVI&OkJ 64/75/97)
�LWSIL!RFACE SOVACd DISP(. 5AI.. S1S'HM INSPECTION FORM
PAR C
SYSTEM INFORMATION ((ontinued)
Properly Address:
ON%rier; 01 Q 0/t r> C1
Date of Inspection;
BUILDING SEWER: { (T
Locate on time Wall)
;)epth bcio�% trade:
V'alerol of (on`.trUctto;l: •_ .;,; Trot) _ .:f1 I'� •fu'r :r�l7i,ln�
Distance irorn private water sut,;;ly or soction hne
D1ameter ---
Cornmenls: (condition of !u vt ntins�, o� ci 'Fite of i,',,k;ge, etc )
SEPTIC TANK:
lo<'ate on ,Ilv pion)
DepIn below mule�'_``(y
material or(onstruction: (/low relc' ,'nc tal -!rhr a ,r. _;`O cth�ione—or her,ex plat n)
If tank is me',J, list .14e — Is am, b� )snit)(.le of Ccsm:))),ante — ,1'esiNol
Dimensions: d00 u'/r
Sluure depth: 0.0
- 3-: e ,,r � . . C2`
Scum thickness: ry
Distance from top of scum to t<,p of of{tlel tee or baflle,-
Oistance frorn bollom of stun, to bottom of outlet tee�tr battle
Hnw dimensions were determined:
is or.nmcnts:
(recomrnenda'ion for pumping, condition v inll),fnd pit: rt u•es or b )ties, depth of liquid level in relation t outlet invert ,truce ral
;Fite rity, evidence of leakage, etc.} r Z �Q
ei e r f 21 i r Q _
GREASE 7 RAP:
(locate on site plan)
Depth below grade.:__—__
Material of construction; _concrete _metal _Ft glass _,Polyethylene,_;,,other(explain)
Scum thickness:
Distance from top of scum to top outlet tee or baffle:,__
Distance from bottom of scu o ixlttom of outlet tee or baffle
Date of last trumping:
Comments:
(recommendation ( r purnprnc;, cowlitieln of MIN and cruller ties or baffles, depth of liquid level in relation to outlet invem, structural
integrity, ewden of leakage, etc.)
page 6 of 10
(revised 09125J9�1
',I BM MA(A s)tl fORM
r'NRT C
'MWON icon [ItI.,
Propvrt� -kc!"russ: XA tW?
ONA ner: N4AablA AOL
0.0c ot lnspe::Iion: �#AS
TIGHT OR HOLDING TANK: r X)k (I I k]SI In.t I"J'f M'('(J W to. : r ('t 1'*)'1)CC1 OW
ccat.'
Doo!h hwo".% ?',Ide:
tat;ra,rl cat ;crisi(uciion concrele _-_:114'1jj
jimensions
CaoziC1ty:__._
Oeiirn flo,.%
alarm level -"iirm in oikinz order
Date of previous pumping:
Comments
condition of ;r!Lt tee, Cr) 110f" ()T aiarrTt and iloal
0I5TR!5UT!C% BOX:---
!ocate on slio plan)
froth o., li,jujj
Cornments, ui st)i I t
e oence ol leal'af:e into or out of box, etc.!
note if It-10 J-1 distribullon (!(!L1tll.
-a�V' �6 &&'& 0
,&
0
PUMP CHA-10CER:
(locate on site plan)
Pumps in working order- (Yes or No)
Alarms in working order (Yes or No)
Comments:
and appurtenances, etc.)
e"'S'
4note condwon of pump chamber, clondit pumps
L.I)StrlaM I. So."A(11-DISPO5U. S}SI[,M 1.\SPLCI It.i IORM
P1RT C
ti}Sll%i 1\1FORNIATION tconlinucul
Property Ac:reps:
O»ner: i♦ 'O it/w/t( q'
Date of 1wectiun: It Ido 93
501L. ABSORPTION S}S-,CM +SAS):_v
Ocate of) we plan. :I nosswie: r`\r,ty.Vu'ln nil! W;1k;' r•cl, tr.il n;,rr l),. bt r)n-iniru: i�C nlelhoo:t
If not ce-,unined to be present, e�t)lam:
?vpe. /
leaching pits, nur'lbl'/_
leaching rharvii-rl-, number:--
ea;Anng galleries, number:
•�a:nine trenches. r.hmber,lengih:�_—•.___--
-aching tuuldS- r.trn:)er, dimension;—_----._--
oye-rflow cesspool, nurnoer.`-
-Oernative system _—
,o-raview.- '
(no;e cpiit, iorl of. soil, },ICns of liv jr,julic failure, e vi-i UI hlln(jwf, conditw:i al :ei,et,d'un Oc')
—l�rf1 s�' �-�Z��� �`� —� e r�lA iv i7 rn
CESSPOOLS: _
(locate on site plan)
Number and conriguration
Depth-top of licuid to inlet Invert:____
Depth of solids layer:_---
Depth of scum laves
Dimensions of cesspool:_--
Materials of construc-tion:_
Indication of groundwater: _
inflow (cesspool lust be purnped as pan of mspection)-. —
Comments:
inote eondltlo of soil, signs of hydraulic failure, level of pondulg, condllIon of vegetatlan, e,tc.)
PRIVY:
,(ocate on site plan)
Nidtt,nals of c0ns1ru(lior,. _ Dimensions:
-ornments.
note eondii;on of soil, swns t)f h4dratill lithe, levr,l of lu riding, condition or ve+;c,ixsmn, etc.)
Itrevieed OJ/]5/97) iV9e s of 10
RIACA. StAltA(ld LASPOSAL S)iSIENk INVECTION FORM
PAR r C
S1SIENJ I\fORkIATIO' (conlinuedi
0%,tner! M4A&OYMA.
Dole of 1l,(.--:::on; A310
SKETCH Of SEWAGE DISPOSAL SYSIEM:
;),Is)(le. ovs t It A 1"v(,) f)(,(ril,if)i-ill wn-rom i nd ri w r or veric i i n mi
:C.Ilo x1 ,wlk thi(xc \�ncry j)i,:?: r .\.ilt,r iuppivc-lics 1010 hoLi-,;
Bat"Ic ba6e
Paj. 9 of
SEWAGE; DISPOSAL SYS7E11 INSPEMON FOR.\)
1 PART C
j SN'51'Psl INFORMATION (continued)
Prot=rty :4ddrea:.: -7
Owner: KenAb ti1�
!)ale of ►nslxcticm: q
ffr
Depth to Groundwater !v FretP.
i `
Pleas- indicate all Oic methods used to deternunc High Gnundu;iter Elcvatuut
Obtainrul fronn !)_sign Plans on rccv:d
�zcxrvatiun of Site (Abutting propcnv. vhservatmn hol,, kascawii, sump etc:.)
51ter-minc it from IcK:a conditions ,
Check with I(xal Board of health
Check FEMA Maps
Check pumping rrcorcls
Check local excavators. installers
use IAGS Data
Describe in your ow'.. wards how sou estah!ished ,he !lit!:G::: ndxa:er gust he comoleted)
was
r
����� Pie 10 of 10
LOCATION ; � SEWAGE_ PERMIT NO.
VILLAGE ..
71'M
- IN.STA LLj R'S �jNAME & ADDRESS
vAkfuo•5 TA•
BUILDER OWNER
DAJ E PERMIT: ISSUED �_2: _77
DATE: 9OM,PEIANCE ISSUIt6 _"77
F
.. ... ._-
i
rt ,,� �/�
II,
*NOTE. ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C.
SECTION ,tom A nu ou,tF,r�rs Fnar THE .. r 7 t A
10' min. from "'A""Bunorl Box"'L BE A L 1 ! 7 t
Existing Foundation' Ise to septic tank covers must beBox PROFILE VIER OF ADDITION TO LEACHING SYSTEM SET LE�41 FOR AT ttwsT 2 FT. 12' c�wcRETE�+ x; 1 t t 3r 1
TOP OF FOUNDATION = ELEV. 100.00 (Assumed) Septic wR 6 to iidre SCOW
of finiafted 9mde _3. r
' Grade over Septic Tel -98.00 Crode over D-Box- nro O0 over SAS- 99.00 3" of l/8" - 1/2" Washed Peast
_ rcrlocxoufs
3/4" to 1 1/2 Washed CrusAed Stone
S - 4-PVC(CAPPED)OISPEC'IM PORT To BE - - }. d, - •, - k
EXIST. or 3• MoeMwn mwr av fd INSTAILID AND 7O BE rM1rIN 6-of GRADE f ( `' ti31 sill Ls � +
5>0.01 T. BOX T OF S em-- Elev. -95.73 -r'. fl i
10 p cr o<.r .- :� :. r It ? g
FROM EXIST. FDUNDAT)Oi � n SEPEXIST,Elm In TIC TANK g t0 CALS- 001-Per foot , a"EMec"we Depth 153- 4" - SCH. 40 T c
! .
I N-io � N 5 PLAN SECTION CROSS-SECTION
CONCRETE Put ,lPlu�7toP►J e to 01 0.83' (10 inches)
5 Untts ! 6,25' 30'
6 Y�.of 3' 31.25 3 3 HOLE H-10 DISTRIBUTION BOX
/ rr - r In w
SYSTEM PROFILE o .
c wnpocted stone o o 37.25` NOT TO SCALE1< T'
Not to Scale S 0 1 O±PPS Ra,d4t iY t 6enawy mZpDS f �8 `f
- > i 4' I 4' 1 Effective Length C�
c o 3 �1 ' SOIL ABSORPTION SYSTEM (SAS)
1,' S GENERAL NOTES
8 tn.of 3/4"-1 1/2" p m
composted stone o Effective �#' o IN'7ILTATROR HIGH,,CAPACITY (H-20 LOADING)/ GEORGE ❑'BRIEN 1. Contractor is responsible for Digsafe notification, Verification of Utilities
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE m (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes.
p
- w Bottom of Test Hole t oev-88.00 NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" -/EFFECTIVE HEIGHT IS 10" 2. The septic tank anj distribution box shall be set
Groundwater observed - NONE OBSERVED level on 6" of 3/4 -1 1/2" stone.
'- 3. Backfitl should be clean sand or gravel with no
- --- stones over 3 in size.
4. This system is subject to inspection during installation
P E R C 0 L.AT I 0 N TEST by Carmen E. Shay - Environmental Services, Inc.
5. The contractor shall install this system in accordance
Date of Percolation Test JULY 12, 20D5 with Title V of the Massachusetts state code, the approved plan
Test Performed By. CARMEN E SHAY, R.S., 'C.S.E. and local Regulations.
Results Witnessed By. WAIVER (Per Barnstable B.O.H_) 6. if, during installation the contractor encounters any
EXCAVATOR: Shay Env. Svcs. soil conditions or site conditions that are different
Percolation Rate: Less Than 2 MPI ® ,; from those shown on the soil tog or in our design
installation must halt & immediate notification be
-- ---- made to Carmen E. Shay .- Environmental Services, Inc,
Test Hole Test Hole
NO. 1 NO. 1 7. No vehicle or heavy machinery shall drive over the
DEPTH S. 1 ELEV. septic system unless noted as H-20 septic components.
--- 8. Install Tuf-rite gas baffles or equals on all outlet tee ends.
DEPTH SOILS ELEV.
0 I 99.00 0 99.25 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
Sand Loam y j
Y Sand Loam I 10. All solid .piping,. tees & fittings shall be 4" diameter
fo tll 3/2 to YR 3/2 �p
Schedule 40 NSF PVC pipes with water tight joints.
0"-12" As 6.00 0"-9" As 8•50 �, 11. Municipal Water is Connected to ALL OF The Residence and Abutting
j Sandy =dy Properties Within 150 Feet.
to YR s/6 to YR 3/1f
` TEST HOLE #1 125.00 \� THE PROPERTY .LINES ARE APPROXIMATE AND
Be 96.E 9'- 30' 8, 97.00 ELEV.= 99.00 f0 5' 37.25' 0' \�� COMPILED FROM THE SURVEY PLAN GENERATED BY
t2'- 32" Madken Medium 4 PROJECT BENCH MARK �� DOWN CAPE ENGIEERING OF YARMOUTH, MA'
Sand Sand i TOP OF FOUNDATION D-Box ���'' �? -_�:�•; '�=�_.s�.. - ENTITLED "FOUNDATION LOCATION PLAN OF LOT41 BETH LANE,
HYANNIS, MA DATED DATED AUGUST 18, 1977
23 Y 7/4 2s Y 7/4 � ELEV. = 100.00 (Assumed) • � �� ,
j3Y- 132 C, 30"- 132 C, 1000 AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
EXIST. TAN GAL IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
I � SEPTIC TANK t O-
THE SEPTIC SYSTEM INSTALLATION.
I I Failed t
j Leach Pit TEST HOLE #2 EXISTING LEACH PIT TO BE PUMPED OUT REMOVED.
O 23 5, ELEV.= 99.25
CS SCREEN I NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
PORCH i FROM THE EXISTING LEACH PIT TO BE DISPOSED
I
OF AS PER BOAR OF HEALTH SPECIFICATIONS.
D EAL S E
LOT #40 � _ �_ � � LOT #42 THERE-ARC. NO WETLANDS ARE'PRESENT WITHIN 7200'-OF THE PROPERTY
DepthPerc #to Perc: 32" to 50" EXISTING it ASSESSORS MAP 272 PARCEL 168 _ _-----
Perc Rate= 2 MPI I 2 BEDROOaf _
Groundwater Not Observed EXIST. SOUSE � ' LEGEND
No Observed ESHWT I GARAGE
ADJUSTED H2O"Elev. = None
o DENOTES PROPOSED
I �
104X1 SPOT GRADE
2-18" DIAM. ACCESS MANHOLES
J I _ /
6 t9 I / , x 104.46 DENOTES EXISTING
1
�� SPOT GRADE
_
b PL PROPERTY LINE
""IT _ \ ou r i EXIST. i ---- �i 96 PROPOSED CONTOUR
` THE ACCESS MY RS FOR'IHE SEPTIC TAW, - - - --
� asTRieuna+ sox APO LEACFiMIG COMPONENT
98 ,� \`� DRIVEWAY LOT #41 --97 EXISTING CONTOUR
"r`.�e•-j-+9�_ >-, - �:•+yr��� SET DEEPER THANR6 INCHES BELOW FWSSWD I �\ I ,
GRADE SHALL BE AISm TO 15,200 Square FeetFVGSHED t
1
STEEL REINFORCED PRECAST CONCRETE DEEP TEST HOLE &
PLAN VIEW INSTALL TUF•-M GAS BAFFLES OR EQUALS
PERCOLATION TEST LOCATION
3-24' M3110V E COVERS i i �\ -_-_ rye
1 �1 -_�------------- 6 FOOT STOCKADE FENCE
ram: 4- - I ' 125.00
PE
non. d.arrmo..- tr PaFr 1
milt 2-min, Inm to Outlet 6-ecM j�' _ I I
OUTLET Catch i
d I-� -�r. a Basin t - --------------- ---- _--___- PLOT LAN
jdfi
f a or awr :. d�0�
OF PROPOSED SEPTIC SYSTEM UPGRADE
B E THE LA NE' PREPARED FOR
MICHAEL & FRANCISCA MENDES
CROSS SECTION END-SECTION (40 FOOT RIGHT- OF WAY) AT
TYPICAL 1000 GA LON SEPTIC TANK # 121 , QETH LANE
NOT TO SCALE H YA N N I S; MA
Desian Calculations
o q PREPARED BY:
Number of Bedrooms: 2 Equivalent to 220 Gal./Day (330 Gol./Day Min. per Title V) �j Y
Garbage Grinder. No T ��' S�� ��� R N G CAR E I li a SHA l
Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) j (7�: IQ 0
Septic Tank : - 2 x 330 Gal./Day =, 660 USE EXIST. 1.000 GAL. Septic Tank. J' 0 S N ENVIRONMENTAL SERVICES, INC,
SOIL ABSORPTION AREA: Using percolation rote of <2 min./inch
Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. _ 273.8 gallons 1 ,p �O P.O. BOX 627
Sidewall Area: 0.74 gal./sq. ft. x 78 sq. ft. s< 58 gallons 0 20 40 50 STEP` EAST- FALMOUTH, MA 02536
Providing: = 331.80 gallons S'4NITAR\P�
TEL/FAX : 508-539-7966
( INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH, SCALE: 1"=20' DRAWN BY: CES DATE: JULY 15, 2005
Use:. 8}
TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE SCALE: 1"=20' PROJECT SD771 FILENAME: SD771 PP.DWG SHEET 1 OF 1
ON THE ENDS. NO STONE UNDER.
I'I
/ FLOPY DES/GA/
` Lot 4Z A/ BEO�E'ooMS
I
EACH ieATE c Z rr„:17/'nc/j
e� I — r-�of ir,c/ud;r,c� �XPat�sior�—
r 3^� lu
N
��rGSE,✓e_ uY �� � o' The req�stereo/ er�9ir�eer whose
I 1 Z
N \•' , ' IZ 2Ppea.rS ors fheSe di'�zWinc?s
res or75;f6/e- or fhe
r` 5v/oer ✓i5ior7 6.r7d CertificQf iorr of
G0r75tr0Cf'/Ot-7 irj 5-�r/C f GZCCorc�OL
h f�ese Plctr�S c�hen a p),Dro ved 6y
bOatd 04- health.
c?o Ile rnir�y
Co
M
-40
SE�.t/r9 G G f� Yo v T O/q Tfl eE S 1r H O L iE' S t/L T S
-- !0a0 a/ sew ovC- fa r�k
iI7/st G le-✓ • G S
�:,vt./�t a/6✓ _ :3'2,yo ;' 2C-�C/�?'� cam+`/ f/c. E.- .:Ui7.r✓ '
— ar�str�but�or, boX <�,p,?.vsy,�,,�,3c �.:.4��•a o�" �' � x�
O a t/e t e/e K 78 !3 - /c� ~ 7 z
—t/ ) ro'�o%Pth) recast leach
�.t /insd c✓, tPh 2 '�rr�, r�) of
washed sto.�a
in/s t e/s✓ = 3/• GS
boJY'or,7 pf / I I'-
fob of f0vr7-4 NOT,* : a// /oCat,or7S Shown a,-e- propo5cc� on/y
la y
1"min.
boar °
• ° °• • •
Tllo/each , • ,
°
'L/ A A_/ o F L. /Q A/Cl /A./
2 /9 /V S T,19 B E H y9 IJA.//5�
fo,- )=,e057- C/9PE- C OD g u/L Cl)I--_ iE's /A/C. _
Sc,2 / " = 30, a/Qtc : 9uGus7- /y77 Cs�Pt'o✓Co/ : Bfl�/�/ST/�BLG
L_O T B O D/-,- 2 7
do�.ur� Gc2�c'� Gr�9ir7Ger/r7Q tNOF,1f,�,._ .
/✓�c: �n16 /NEG�,t S tAM. ,
G AA/O Svc' S EMMAN y
¢lam
,eo co/rG- d A-•- yi'9.IeMo c/Tf,r , ivr�s S cr a f e __ `�soN�►�.��� ` ._._
„� 77- ooz