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LOCATION SEWAGE # _
VILLAGE �WCAIAIS ' . ASSESSOR'S MAP & LOT 2S Z
INSTALLER'S NAME&PHONE NO. R
SEPTIC TANK CAPACITY N
.LEACHING FACILITY: (type) (size)
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NO.OF BEDROOMS
BUILDER OR OWNER L —Q
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PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility //���� Feet
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RECEIVED
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIR SEP 3 0 2002
DEPARTMENT OF ENVIRONMENTAL PROTECTI `TOWN OF BARNSTABLE
_ HEALTH DEPT.
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TITLE 5
OFFICIAL INSPECTION*ORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM FORM
vE; PART A
s CERTIFICATION
Property Address: 12 BISHOPTERRACE HYANNIS, MA 02601 � Z'
Owner's Name: LENA CARLMAN
Owner's Address: 12 BISHOP TERRACE HYANNIS, MA 02601
Date of Inspection: 9/10/02 . O
Name of Inspector: (please print);, , , JOHN GRACI
Company Name: SEPTIC INSPECTIONS i)JC,'
Mailing Address: P.`6 BOX 2119 TEATICKET, MA. 02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
1 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:
X 'Passes , `
_ Conditionally'P ' es'
_ Needs Further aluation by the Local Approving Authority
Fails
— � ' of
Inspector's Signature: a Date: 9/10/02
The system inspector shall submit a opy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the
inspector and the system owner shall,submit the report to the appropriate regional office of the DEP.The original should be.
sent to the system owner and copies,sent to;the,buyer, if applicable,and the approving authority.
Notes and Comments , R:,
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****This report only describes conditions at the time of inspection and under the colldlli011s oI Ilse HI thM lilnl`.This
inspection does not address how the system will perform in the future under the same or different conditions of use.
Titles 5 lncnvrtinn Rnrm 6r15Oldhn
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Page 2 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
' CERTIFICATION (continued)
Property Address: 12 BISHOP TERRACE HYANNIS, MA 02601
Owner: LENA CARLMAN
Date of Inspection: 9/10/02
Inspection Summary: Check,A,B,C,D or E/ALWAYS complete all of Sectiw D
A. System Passes:
X 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 PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
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.
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Answer yes,no or not determined(Y,N,ND)'in`fhe for the following statements. If"not determined"please explain.
n/a The septic tank is metal and over 20'`years old* or the septic tank(whether metal or not) is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if,a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or'break.ouror 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
_ obstructior is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping m 'more 4,times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a �,;,,•
Page 3 of 11 l.a
OFFICIAL INSPECTION"FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 12 BISHOP TERRACE HYANNIS, MA 02601
Owner: LENA CARLMAN
Date of Inspection: 9/10/02
C. Further Evaluation is Required by, the Board of Health:
_ Conditions exist which require furtherrevaluation 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 Boa,rd'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 ofa'surface water
_ Cesspool or privy is within 50`feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manIner that protects the public health,safety and environment:
'
_ The system has a septic tank'a6d soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surWe'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 SASIand the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank ana 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 n/a
"This system passes if the'well'"water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicdcsffiat the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy
of the analysis must•be`attached to this form.
3. Other: '
n/a �
= 1
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Page 4 of I 1
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 12 BISHOP TERRACE'HYANNIS,MA 02601
Owner: LENA CARLMAN ij
,.
Date of Inspection: 9/10/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each"of the;following for alLinspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
_ X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
X Required pumping more than.4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped 1 YEAR AGO" OWNER.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone l of a public well.
_ X Any portion of a cesspool,or privy is within 50 feet of a private water supply well.
X 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 coliforin bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility'and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided'that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.1
(Yes/No)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 wil 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.
You must indicate either"yes"or"no`to each of the following:
(The following criteria apply to large+s_ystems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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
"ycs' in Section D above the Ali ige`syslem h.is(inlet,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.
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Page 5 of I l
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OFFICIAL INSPECTION+FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 12 BISHOP TERRACE HYANNIS,MA 02601
Owner: LENA CARLMAN
Date of Inspection: 9/10/02
Check if the following have been donei.:'You must indicate "yes" or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
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X _ Has the system received normal flows in the previous two week period`?
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X Have large volumes ofiwater been introduced to the system recently or as part of this inspection'?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dweltireg inspected'for signs of sewage back up?
X _ Was the site inspected for signs of break out'?
X _ Were all system components,excluding the SAS, located on site'?
X _ Were the septic tank maAafeg uncbVefed,opened,and the interior of the tank inspected for the condition of the
baffl
es or tees material of construction,dimensions,depth of liquid,depth of sludge and depth of scum '?
X _ 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:
Yes no
X _ Existing information. For"example,a'plan at the Board of Health.
X _ 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(3)(b)]
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Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 12 BISHOP TERRACE HYANNIS,MA 02601
Owner: LENA CARLMAN
Date of Inspection: 9/10/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3"'Num6er of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or'no) ;NO
Seasonal use: (yes or no): NO '
Water meter readings, if available(last 2,years usage(gpd)): Or 01
Sump pump(yes or no): NO 0(1 u f�/ •` k
Last date of occupancy: n/a 10
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15:29,,3):-r:/agpd
Basis of design flow(seats/persons/sgft,etc.)-, n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present.(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records %
Source of information: 1 YEAR"AG6BY OWNER
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons i=46' was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM.
X Septic tank,distribution box,soil'absorfion 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)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
F
Approximate age of all components,date installed(if known)and source of information:
29 YEARS BY OWNER
Were sewage odors detected when arriving'at the site(yes or no): NO .
Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART C
SYSTEM INFORMATION(continued)
Property
I MA 02601
• 12 BISHOP TE
RRACE H YANN S
r y Address.
Owner: LENA CARLMAN
Date of Inspection: 0/10/02
{
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron 40 PVC Xother(explain): ORANGEBURG
Distance from private water supply well'or suction line: n/a
Comments(on condition of joints,venting, evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age.confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' T!''W 4'10""
Sludge depth: 1"
Distance from top g of sludge to bottom of outlet tee or baffle:33"
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Scum thickness: 0" •
Distance from top of scum to top_of.outlet tee or baffle: 6"
Distance from bottom of scum to Bottom of outlet tee or baffle: 18"
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.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERYTWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a ;, .
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
n/a
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Page 8 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 BISHOP T`ERRA.CE HYANNIS, MA 02601
Owner: LENA CARLMAN i
Date of Inspection: 9/10/02
TIGHT or HOLDING TANK:- (tank must berpumped at time of inspection)(locatle on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons " F
Design Flow: n/a gallons/day= `x
Alarm present(yes or no): N/A'
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: _(if present thust'be�opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments(note if box is level and disthb'u.t,an to outlets equal,any evidence of solids carryover, any evidence of leakage into
or out of box,etc.):
n/a
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PUMP CHAMBER:_(locate on site plan) slr
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,,condition of pumps and appurtenances,etc.):
n/a
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Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 BISHOP TERRACE HYANNIS,MA 02601
Owner: LENA CARLMAN
Date of Inspection: 9/10/02 t
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a
"id,
innovative/alternative system
;A Type/name of technology: n/a
Comments(note condition of soil,ksigns-of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF
FAILURE. PIT WAS HALF+FULL AT TIME OF INSPECTION. PIT HAS T OF LEACHING LEFT IN IT.
BOTTOM IS AT 8 FT.
CESSPOOLS: (cesspool must b6:10m'ped 8-part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition ofsoil,sF gns;of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
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P-age 10 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 BISHOP TERRACE HYANNIS, MA 02601
Owner: LENA CARLMAN
Date of Inspection: 9/10/02
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.
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OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 12 BISHOP TERRACE HYANNIS, MA 02601
Owner: LENA CARLMAN
Date of Inspection: 9/10/02 ;t
SITE EXAM
_Slope
_Surface water ;
_Check cellar
Shallow wells
Estimated depth to ground water 12 ,feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explaiii,:.,n/a
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You must describe how you established the Nigh ground water elevation:
HAND AUGER- 12 FT.
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