HomeMy WebLinkAbout0199 BETH LANE - Health 199 Beth Lane -
272-162 Hyannis
i
* s ,
t
4�d 1.��' tit'.a+.r
F
• 1 a - 1. f + . * .. � r i
. G , D },
t
Vln
2'
NA
'k Q
.............
........
F'it;a
MR,
5E�
..........
.... . ......
va
_PW
Um
M-L:4f-4
t ZI
q7'q7'_i7q7'
gift
ME
MA
........
Ol
5N
mum WIN
Commonwealth of Massachusetts 07 &2-f(e
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
199 Beth Lane Assessor's Map: 272 Parcel: 162
Property Address
Dorothy C. Ryan
Ownerry Owner's Nam
inforrntion is req Hy annis MA 02601 October 29, 2017
uited for every
page,.-:,, Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not David D. Coughanowr
use the return Name of Inspector
key.
Eco-Tech Rapid Response
�y Company Name
155 George Ryder Road South
Company Address
f Chatham MA 02633-1621
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes OF04
SsgC El Conditionally Passes ElFails
❑ Needs r� r tatioy� the Local Approving Authority
a COUG NOWR
. � N .13
q October 29 2017
Inspector's Sign rFM /NSPCC. 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 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
1/1
Us
Commonwealth of Massachusetts t ,
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
199 Beth Lane Assessor's Map: 272 Parcel: 162
Property Address
Dorothy C. Ryan
Owner Owner's Name
information is required for every Hyannis MA 02601 October 29, 2017
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate
Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-
5, or specified by local regulations. The scope of this inspection is limited to health and environmental
compliance and the septic system has been evaluated according to the conditions observed on the
day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination.
B) System Conditionally Passes:
❑ One or components mores stem as described in the "Conditional Pass" section need to be
Y
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 cr 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 199 Beth Lane Assessor's Map: 272 _Parcel: 162
Property Address
Dorothy C. Ryan
Owner Owner's Name
information is required for every Hyannis _ MA 02601 October 29, 2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
-pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (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.
C.'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.doc-rev.6/16 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 199 Beth Lane Assessor's Map: 272 Parcel: 162
Property Address
Dorothy C. Ryan
Owner Owner's Name
information is required for every Hyannis MA 02601 October 29, 2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
99 p
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '%Z day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
l �
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 199 Beth Lane Assessor's Map: 272 Parcel: 162
Property Address
Dorothy C. Ryan
Owner Owner's Name
information is required for every Hyannis- MA 02601 October 29, 2017
page. City/Town 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
q P - P 9 Y 99
❑ ® 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
pf;ammonia nitrogen ard nitrate,nitrogen,is eq,pal to.or less than 5 ppm,
provided that no other'failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a,mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts ,
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 199 Beth Lane Assessor's Map: 272 Parcel: 162
Property Address
Dorothy C. Ryan
Owner Owner's Name
information is required for every Hyannis MA 02601 October 29, 2017
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 Heafh.
® ❑ 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): n/a
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage:Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
199 Beth Lane Assessor's Map:272 Parcel: 162
Property Address
Dorothy C. Ryan .
Owner
Owner's Name -
information is
required for every Hyannis _ MA 02601 October 29, 2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
No design plan was found at town offices. Disposal Works Permit application of 1995 states 3
bedrooms.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use?j _ .. _ . ❑ Yes ® No
Water meter readings, if available last 2 ears usage (gpd)): 137 gpd
9 ( Y 9
Detail:
2015: 40,395 gallons 2016: 59,844 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.):
- Grease trap,present? ,: ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
l
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 199 Beth Lane Assessor's Map: 272 Parcel: 162
Property Address
Dorothy C. Ryan
Owner Owner's Name
information is required for every Hyannis MA 02601 October 29, 2017
page. City/Town 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: owner
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 co of the DEP approval.
9 copy pP
❑ Other(describe):
t5ins.doc•rev.6/16 Title 5 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 199 Beth Lane Assessor's Map: 272', Parcel: 162,
Property Address
....Dorothy C. Ryan
Owner
Owner's Name
information is Hyannis MA 02601 October 29, 2017
required for every- y -
.page,..._ _. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 22+ years. Certificate of Compliance for a new leach pit was issued 4/28/1995 (Permit#95-1516
at Health Department).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+feet
Comments (on condition of joints, venting,.evidence of leakage, etc.): 4
No evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age::' years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 9.5' x 5' x 6-1200 gallon
Sludge depth: 4 inches
t5ins.doc•rev.6/16 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 199 Beth Lane Assessor's Map: 272 Parcel: 162
Property Address
Dorothy C. Ryan
Owner Owner's Name
information is
required for every Hyannis MA 02601 October 29, 2017
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 Winches
Scum thickness 1 inches
Distance from top of scum to top of outlet tee or baffle 9 inches
Distance from bottom of scum to bottom of outlet tee or baffle 14 inches
How were dimensions determined? permit application form
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time. Maintenance pumping is recommended within 2 years and every
2-4 years thereafter with year round occupation. Tank and tees appear structurally sound and
functioning as intended. No evidence of leakage in or out was observed.
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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Cisposal System•Page 10 of 17
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°�M ,•' 199 Beth Lane -Assessor's Map: 272_ Parcel: 162
Property Address
Dorothy,C. Ryan
Owner Owner's Name
information is '.
required for-every His x _ _ _ MA., 02601 October 29, 2017
page. _ Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
s
❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 199 Beth Lane Assessor's Map: 272 Parcel: 162
Property Address
Dorothy C. Ryan
Owner' Owner's Name
information is required for every Hyannis MA 02601 October 29, 2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert at outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
No adverse conditions observed.
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.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc-rev.6/16 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
CG1M , 199 Beth Lane Assessor's Map:.272 Parcel::162
Property Address
. Dorothy C..Ryan .. .-.
Owner Owner's Name
information is ;- MA 02601 October 29, 2017
required for every' Hyannis`_ . _ _ `
page. , �City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ 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.):
No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was
observed. A hole was dug into new leaching pit stone and.no effluent contact staining was observed
in the stone or overlying soils. No standing effluent was observed to a depth of 2 feet below the top of
the peastone layer.
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.doc•rev.6/16 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
^M 199 Beth Lane Assessor's Map: 272 Parcel: 162
Property Address
Dorothy C. Ryan
Owner Owner's Name
information is required for every Hyannis MA 02601 October 29, 2017
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage DI-sposal System•Page 14 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
199 Beth Lane Assessor's Map: 272 F":.Parcel: 162 "'�M SvOye ..
Property Address
Dorothy C. Ryan
Owner Owner's Name
information is
required for every- • __.._Hyannis `' MA . 02601 October 29, 2017
-
page. Citylrown, State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
SEPTIC _ FC A'T
�CCeg�CH.I�s..
O*
O
LEA CH 0J�\
PIT J Q LEACH rL— OCA T§ONS
4 ` 21 PIT -OF SEPTIC COMPONENTS
-DISTANCES A IN DECIMAL FEET
i 8
THIS SKETCH IS 1200 GALLON
BEST VIEWED IN SEPTIC TANK 1 19 7
COLOR FORMAT 2 25.5 11
A -- B 3 46 . 29
4 20.5 34
EXIS TING
D V�PI ELUNG
NOT
3 n TO
cc a SCALE o
z
O
PCS�
UETH LEAN
508 364-0894
t5ins.doc•rev.6/16 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 199 Beth Lane Assessor's Map: 272 Parcel: 162
Property Address
Dorothy C. Ryan
Owner Owner's Name
information is required for every Hyannis MA 02601 October 29, 2017
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: 25+
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: P .,Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database -explain:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is over 25 faet above
groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
� Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 199 Beth Lane. Assessor's Map. 272 Parcel: 162
Property Address
Dorothy C. Ryan _
Owner ... .___ .... .. ._ .
Owner's Name
information is
required for every Hyannis MA 02601 October 29, 2017
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
GEOHYDROLOGICAL PROFILE
— NOT TO SCALE
II T 11. 11 T
p, v PRECAST ass a of
' LEACH b
PIT
41
Ili e
N :LEACHING
TTOM
OF
PI T
'LEACHING IS
ABOVE HIGH
GROUNDWATER
GROUNDWATER ELEVATION
PER GIS MAPS
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
TOWN OF BARNSTABLE
LOCATION SEWAGE # S�'jS�16
VILLAGE Ny_c,el yj'5 ASSESSOR'S MAP & LOT s Z
INSTALLER'S NAME & PHONE NO. g►l( �fabinSon ?��7��
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) to o c'i f �� (size) !or
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER Pu ' jc
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
�r
Q/ `
a � �
0
��
i^
i
CT'
'�
G'1 � � .�
i
��
,$ ird
t.11 J
�� Q
� �
,\
ASSMSORSMAP
PARCEL
THE COMMONWEALTH OF MASSACHUSETTS—
BOARD OF HEALTH
TOWN OF BARNSTABLE
Application is hereby made for a Permit to Corj_,t�-uct or Repair ((--�an Individual Sewage Disposal
System at:
L t' -Address or Lot No.
ow Address 'r
Address
Type _ Building Size feet
Dwelling of Bedrooms-�--��--_--_--_-' Ex Attic ( ) Garba�r (}r�xl�c�( )
Other—Typeof Building --------- No. of prr000s-.. -.-.----- 66mrcro Cafeteria ( )
^° Other fixtures ---------'--_-_._., _______._____________.______
'- l�u.�-_---.. D�ont��------. Depth below ---_. .-- Total leaching area leaching --.-'--. ^
S��ya�c Pitq. t.
Z (}t6cr - ) Dosing tank ( )
'- Percolation Test Results Performed hy----------------------------------------------........................... Date........................................
Test Pit No. ]................miuutcspecinc6 Depth of Test Pit-------' Depth toground water........................
;X4 Icat Pit No. 2-.............minutes per inch Depth of Test Pit -..__.-- Depth to ground water........................
pn ---. __-_-'--____
0
Description of Soil-. -.----_.---____--_ _
''--.--.-'--.-_-'_.-__--'_.-__'---^=_`..^--_.-.---_-_--'-___--'_--'----_--_-'__---
'
--.-'—'_---_—''..--.-'''-'''-''_.---.--.---.-''----'-_.---'.--'_-''---__-.____-
U Nature of Repairs or Alterations--Answer when applicable-..- �������..
/ .uiu
� Agreement:**
� the provisions of ITITLE The undersigned agrees
[oJ� The Sewage ' System
5 c6 the State
r agrees not to place the
system in operation until a Certificate of Compliance has been i;su d t
---------------
~~
� Application.Approved mf-7--- --- - -----------:--___----_
Dm
Application [)�u 6n�6 ��
Fmc
No
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
54 TOWN OF BARNSTABLE
Appliration fur Di-tip'!ial Work,5 Tomitrurtiun lirrutit
Application-is hereby made for a Permit to Coris&Uct ( ) or Repair (4�an Individual Sewage Disposal
System at:
'I Location-Address or Lot No.
............ a__1.--- 1.. ----•-•-•=-•-•--------•---•-•••---•-----•-•••--••---•-- ••--- ----•-•--------••-•••---•---•-••••-...------•••--•-•--••••---------------•••----
Owner Address w � It - �
Installer Address
Q Type of Building Size Lot.............................Sq. feet" -
2 Dwelling— No: of Bedrooms._:._..3-----__-•_______________________'•Expansion Attic ( ) Garbage Grinder ( )
aOther
—Type of Building -----&',_____--------------- No. of persons-------__.__-------_.---- Showers (,'�,) — Cafeteria ( )
d Other fixtures --------------------------------
Design ---------------- ---•-----------••--------•••--••--•--•••-•--------...------•.
R: Se Tank—Liquid capa -gallons per person per day. Total daily flow--------------------------------------------gallons.
_... .. Flow-------------- --- -- - -
• city_11�__gallons Length.-a`"--------- Width.1'_........ Diameter---------------- Depthf..
x DisP Seepage l\I tench—No. ..................• Width-------------------- Total Length-------------------- Total leaching area-.--_-------___---sq. ft.
Z Other Pit No.-I----
box ( ) Diameter-- Dos Depth below inlet.................... Total leaching area..................sq. ft.
Dosing tank ( )
aPercolation Test Results Performed by........ -------------------............................................... Date........................................
Test Pit No. 1__--------------minutes per inch Depth of Test Pit._..._._.____...._._ Depth to ground water.......................
f= Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.........................
------••-----------•-•- -
--•---••••-•----------•-------•--------•-------•--------•------•--•--------•-------•--•••------
O
Description of Soil.... . ; --••
U ------------------ ....................................................................................................................................................................
x .............. ----- ----------.....---....------•- -••-- ;------�-----_-....................-- . ........_._
U Nature-of Repairs or Alterations Answer when applicable.---"�-�"?Zq)j..._llt&4..1�°_ x•.�?.�-�e_'t~••/�x�c?•�*��a
Qr . ..
-------- ------------------------------
Agreement: r
The unde.rsi# Tied agrees-'to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions ofTITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation.until a Certificate of Compliance has been issued b t � oard of h alth.
r.
Signed --- _. .......... .........
Dace
ton Approved B Application. ...... -----
- Dace I
7-------
Application Disapproved for the following rearonf: ................. :..
..........................................e ...... -. _..............---------------
..---.--._........-....:.---.------------------------------ ---..-..--...---Da......-------------
Prmit No. -1... ............... Issued .......� --
Dare 1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(ger#ifi ate of ( omplianrE
THIA IS TO CERTIFY That the Individual Sewage Disposal System constructed ( ) or Repaired (t/)
by- Ub-^Qo- -----sev_+c.....�. �1ev�................. ..._..... labs -C C .i a-r ,1Ie....-
� •
`,_..... -- ...... - ...
tn,aue
at " g� r11 — -- ------- ....... ...... ... .. .......... . .............__................has been installed in accordance with the provisions of TITI f h State n ironmental Code as escribed in
the application for Disposal Works Construction Permit No., .-,� -.14 -.- dated o�_ "-
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
D •^....�,p '------------ ---- Inspecto _...-..... .�/.��.... ---------------
ATE
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE - oo
No... FEE...............•_.......
%vosa1 luorku Tonntrurtivit Op"erntit
Permission is.hereby granted.................................................................................
..............................................................
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
at No..3' l
,11 �ob,�r�,r .Sc �!c Sef�,cq ----•--•- "k---SUS 1-----C@rl tc,--��---��...�4,..................•-----•---....----
as shown on the application for Disposal Works Constructionvrmi -.---��f� �""9��
f Dated _•----- --- --_--. ------••--
wool
�}� Board of Health /
DATE........ ." _..--------•--%------=h-`9-'--� -----------------------•- f
FORM 36508 HOBBS&WARREN,INC..PUBLISHERS -
Kf, c _
No. S Fss..... ®�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
__._.... _ ......... -- OF.........................................................................................
Appliration -fax 13iiiVooa1 Workii Tonstrurtijatt Vrrnift
Application is hereby'm a for a Permit to Construct (� or Repair ( } an Individual Sewage Disposal
System at.*
-�------34--------------......... ..........
o A r ss Lot No
........ ......•... ---- .•... ••• ...................... ....... ....... •• .
W Owner A ress
/ ,
� Installer Address
Q Type of Building' Size Lot_./_?-/_4-9......Sq. feet
U Dwelling—No. of Bedrooms=__.___. Expans' n A i ( ) Garbage Grinder ( )
�-+
p1 Other—Type of Building .___.__.._-- ____ No. of persons. Showers (7,i — Cafeteria ( )
:x pi Other fixtures ..... .
Q --•---•------•-•---------- --•----............. ----------•-----------------------
W
Design Flow................. ............gallons per person per day. Total daily flow.,_.._......33, 42.._..__.._._.-_-gallons.
WSeptic Tank—Liquid capacity,/000gallons Length................ Width_____- Diameter-------.-_.----- De h.__._-___._._.
Disposal Trench—No_ ____________________ Widt__X _----___- Total Length..-_-__-____..____ Total leaching area__ --------sq. ft.
- x -
Seepage Pit No-------/............ Diameter____________________ Depth below inlet.................... Total leaching area___-.__-_____-sq. tt.
z Other Distribution box ( ) Dosin tank )��
Percolation Test Results Performed b ..__. .__ __-- --------------------------- Date. �.-1-- _______-----
a Y "'`. 3 4
a Test Pit No. I........ per inch Depth of "Pest Pit____________________ Depth to ground water.---------------__.____.
(i Test Pit No. 2................minutes per inch Depth of Test Pit-__:___-____----_- Depth to ground water------------------------
-----------------. .-:.-------------------• ------•---•==z- .................................................•---••-•-•••-•••--•---••----•----------------•---------
O Description of Soil------ =' �-- �.......... ^ .......................i .�- ---
U1-= -� �` -ZZ- .................................................-••--•-•-----•----•--------------------------------------•-------
W •---•----------- ---------•----------------------•----------------•--•------------•-------•-------------•---•-----•---------------••--•-----•----•----•-•----•-•--------------------------- ------------
UNature of Repairs�or Alterations—Answer when applicable.--------------------------------- ---------------------------------............__-._.__-_-___.
--------------------------=-----------------------------------------------------------------------=-----------------------------------------------------------------------------------------------
Agreement:
The undersigned agrees to install the afore_described 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__-_ �3� - --------------------------------
Date
Application Approved BY 77
( ..`C.....---•-•--•--•-----•--•-------••--------•---------------•-•------ ----- �. e
e .-..
Application Disapproved for the following reasons:----••-----•---------------------•------------------..-----•----•--. -•- ------..-------------
----•---•---------•------------------------------•--`------•---••--------------•--••--•------------------•---•------------------------------------------------------------.-----
Date
Permit No....If4- Issued...... y ------------------
-- ------------------•------------ Date
No.. r Fw$.-.... ,�...�
y 4
THE COMMONWEALTH OF MASSACHUSETTS ,... - .�-----�^--
BOARD Or HEALTH
F '
Iiration -for INnipoiittl World Cnonvorurtton Pprutit
Application is hereby'm e for a Permi to Construct ( `"or Repair ( ) an Individual Sewage Disposal
System at:
9 - ........ Ey
. '' Loc r Lot No. t
k- 1 -- -• .....__... -- -5 --- ..........
K ^; fOwner Address
c W ------
P
Installer Address
�+ ¢ Type of Building Size Lot_-/_ j_.G f3__:___Sq. feet
I U . Dwelling—No. of Bedrooms____ ____.___:-_-Expans A G bage Grinder ( )
.-� �,-C9'� - T
} p� Other _Type of Building ________ _________________ o. of persons. _________ :.. .___.-_: Showers ( — Cafeteria ( )
1, d Other futures -- -- --- 'r
Desi n Flow -_______________ J..�.._.___-. allons er et-son er da Total dail flow..._.._.____._..: _. gallons.
W ��, g -------- g" P P P Y• Y - --------- g�
,Septic T autl. Liquid capacity Od gallons Length__________-_.__ Width..____ .. .._. Diameter---------------- _ s
e Dlspotdl Trench—No ___________________ Widt1 __� _____ __Total Length------------------._ Total leaching area-_- sq. ft.
3 2. Seepage Pit$No r/ P g < 1.
____ Diameter____________________ De th belrnv inlet:.._________________ Total leachin ire 1-,___._-__-_ __.__sc ft.
} Z Other Distribution box ( ).r,-• Dosing tank ( )
a 'Percolation Test Results Performed by-_. Cl�" ---fie. ............................... Date------9/1- �?
Test No. 1------- ---minutes per inch. Depth of "1 est Vat, _______.___- Depth to ground water. ______
L14 Test Pit No. 2________........minutes per inch Depth of Test`P t,. _____-_______ Depth to ground water .._.___-. ____-_
••---- --.. w ---••••-••----•.•--------..................................._-------
,,.; O Description of Soll O 2 " € + _ ._---•---------------- -------------:-- ----- -- -----------------
U •- --- ------ ``�__----e V A_1.. �" "-"--------�'n�.�-- �' -------------------------------- ------------------- --
_ - ., W n
x -•--------- - - -- - •-------- -------------------- -__----- ------------------- -•----•••---------•----------•---------------
U Nature of Repairs or Alterations—Answer when applicable--________.._ .-._
---------- --- ----- ----------------------------------------------•-------------------••-- ----- --------------•---•------------------- -------•---------------------
Agreement '
The undersigned agrees. to install the aforedescribed Indi'viduA"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 issued by the board of health.
Signed-�` -- - •---------•--------- ---- ----- ------ ---- -----------
Application
µ ,F
A roved B
PP Y= ___•---------------------•--------------------------------------------------------- ......................... ----
- e-
APPlicatioty Disapproved for the following reasons:----••---------•--------•------ -------------••---- = ••-•••----
-_---•-� ------- -,--•-------•-------•------------------------ ------
V Date
. d
:,,Permit,.No.--• Issued. -----•---•-_...._
Date
kTHE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
d 0
s �x7
. ....... ..OF...... . 'r� s. . . .. :....................
� -- �rrtifiratr of Tom haure x Ft`
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
In11 - -- -------- -------�� .___-_--
at .
has been installed in accordance with Abe prove' ions of Artu X of The State Sanitary Code as described in the
application for Disposal Works Pbtruction P6x�mit No _____________________ dated....... __:a .. ..- .._____.___.___ -
J F ,
THE ISSUANCE OF THIS CERfl,,F#CATE�SHALL'N.OT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL, FUNCTION SATISFAdT'ORY. ,s
DATE
t
Inspector....................................................................................
THE COMMO)'NWEALTM OF MASSACHUSETTS
"
BOARD OF 'HEALTH r
............................. ...... .OF.-.- .... .�tcJ Ja
i� iittl Mork , mitrurtion Vrrmit�'�c
Permission is hereby granted ... . tl _. ---•-•---
to Construct (X,) or Repair,( ) an I 1vlduals Sewage Disposal Sys em
at No........ - - --------.'�'%�� lC- -��'�'� -----------------------
G} ;
)�� •�� Street �b
y
as shown on the application for Disposal Works Construct on P rrzutr No . ,,' ._____ Dated---- •. .. "'"___..__(______..__ �
t 'I; s
...................... . --------
DATE--- -��' d f Health
- ----- . .---•--.._.- -----•................ -----------
INC.. •".....,,.ev oar o B Hea
FORM 1255 HOBBS & WARREN PUBLISHERRS -
,� 1 ;;:':#� .� ___..�..nm.,ay,,,y�,�TMi'� `r / -� s< �'� ) �°'' 4•!y,'s v'�A�i`T t J - � .. .. i�c C`.
sP`.:aE`, -...n� .,....,. .,fa` ,.�... ... *�,_...,.i-, _ ...._.,._...-..F cr•,a...,c.- w._... .«), .•. _ -,+.+�v^nx^,3'�',K .-.... ... »-. ., � i. .�
TOWN OF BARNSTABLE
LOCATION 09 84tL LN • SEWAGE # 17" sag
VILLAGE 14 `/;�i li 4 't S ASSESSOR'S MAP 6 LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER Public
BUILDER OR OWNER Ja
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
itb ;01
_ 4
i
t
� s/GA-1 J-- /./c/,L
j G.E�4Cf-/ ,FATE• c Z rr7:�.�ir�c L;
• . ,� -__� �`o � , � P,eo f'o 5 E o L E �l c N Aye E.9
-
G O T ��S
1 3Oco ' 1
CreaC��e Q � ZT6 The regist:0 eo/ er-?yir�e�r !A-,A?
or? E E c7 r'c3,�
be resPor7s, 6!e for-
4 fhe
Supervis.oh ar,d certif;cat�nrr o
Cor7S7` Y! C..fiOr/ ;� r�i�c�' GZCCOY�r2r-.0
5 I+
� � �fh These �/czr� U�-Gier� cz-��roved b�
4
31.�ir� J , 1 The c�overr>>r�q �c a C f �?e 5t:�f�7
Otc
G p
J?O�o
I�
I
SE44/,,96E- 4,o,9yOU7- L��97-r9 TEST HOC_ .ESE S(�LTS
— /DOD 9G2/ `7-5
o�t/e>` e/s✓ _ Z 1 S� a � /��3"v�Ts s.�. ,��c,�� Gv�=-y =�'�'
l�IU/.�/✓ Jc-�fcI.�S'C ` ,.GXj/'�/a�`i� Lit /�-/��9L�'��
— disf'ributior7 boX i
/,7le/" e/e✓ _ " 7 ' S c� La Ia.-
0 C/71-le 71- e le-✓ = Z . Os
—��) 6'6dePth) Pr'eCca67` !each
"o/t /i/7Co/ 4&w/7of7 Z '(h-i.1n) of
mashed Stone
in/e t ale✓
bo74torr7 of P/ t =
-?oP o f 'fOUe-rd. NoTe : a// /oca.tionS Showr7 cart proposed/ on/y
e% = 3e./
�Ltc,er of
- „rn/n /fch Per �ICoot -- - - ' PeaStor7e. -
,toy. 18D /000 9a/ aGsrribut�on box
T"le
N_scale1ach ,
u.ass,cd ° • ° 6 P� t ° °
°
°
°
°
' • °
°
1 Ogg
/o
�or F�20ST Gfa.�'E- CJ' L7 !3 UlLG�E�'S l�llG.
977 a�P�o ✓ed F'�9,��.'ST��� �
6a r-7,7 : �_ o T 35 �� FCC 9A-1 B OOA' 0 7/1 BoA,2o o� HE�7� TH
ova t G
<<Y �f MASS
d0 c,cJ r7 G' c2 P e e r-7 9�r7 G e r i r-7
JAME$ yG�
C BOW
MAL fir@
dGt 7L G
# �?-Ova •