HomeMy WebLinkAbout0070 BISHOPS TERRACE - Health F3` '70 Bishops Terrace
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TOWN OFBARNSTABLE
,OCAIION �. 5 c S /eel-c- c e SEWAGE #
'ILLAGE ��✓1 c`3 —ASSESSOR'S M"& LOT—_
RI,&: LER'S NAME&PHONE NO. �
EMC TA.NIC CAPACTTX 000 �� � � I
EAC�ILMNIG FACT.�.TTI': (type)�: � 1. (size)
rO,OF'BEDROOMS
ILTILDER OR OWNER i
FRMI<TDA'TE: acoI LIANCE DATE:
eparation Distance Between the:
Raximum Adjusted Groundwater'llable to the,Bottom of Leaching Facility eet
'rivate Water Supply We0l and Leaching Paacit tyl(if any wells exist
on site or wetbin 260 feet of leaching facility)I ____ _E, eet
Age of Wedand and Leac0ung Facility(If any w',lands exist
wither 304 fer�, ° leachinym-
st�i / -_ �eet
tarnished by 52h644. fit
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TOWN OF BARNSTABLE
LOCATION 76 �� S �� Src.c.�. SEWAGE # �'^S
VILLAGE "4- r;, S ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILrrY: (type) (size)NO. OF OF BEDROOMS 72
BUILDER OR OWNER
PERMITDATE. f 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) iv 9 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist Nl� Feet
within 306 feet of leaching facility)
Furnished by /;
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 70 Bishops Terrace
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name -
information is required for every Hyannis MA 02601 12-15-10
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.
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
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:
® jPasses ❑ Conditionally Passes ❑ Fails
6
❑$Needs Further Evaluation by the Local Approving Authority
12-15-10
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
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
I
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposa yste
m•Pa 1 if 5
,
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 70 Bishops Terrace
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Hyannis MA 02601 12-15-10
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 sign of failure. Recommend pumping tank and leach pit
every 2 years for maintenance and to prolong 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.
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.he 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:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s1 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Bishops Terrace
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Hyannis MA 02601 12-15-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont_):
❑ distribution box is leveled or replaced
ND Explain:
❑ 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
❑ obstruction is removed
ND Explain:
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
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 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Bishops Terrace
Property Address
Bank Owned (Contact Daryl[ Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Hyannis MA 02601 12-15-10
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:
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 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
l
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 70 Bishops Terrace
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Hyannis MA 02601 12-15-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No'
❑ ® 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-
I0,000gpd.
❑ ® 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
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 CM 15.304. The system owner should contact the appropriate
regional office of the Department.
t5insp official document•03108 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
70 Bishops Terrace
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Hyannis MA 02601 12-15-10
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 maintenance of subsurface sewage disposal systems?
proper 9 P y
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 CM 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
�M 70 Bishops Terrace
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Hyannis MA 02601 12-15-10
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
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
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy:
8-2010
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:
Last date of occupancy/use: Date
Other(describe):
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Bishops Terrace
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Hyannis MA 02601 12-15-10
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:
1972
Were sewage odors detected when arriving at the site? ❑ Yes ED No
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Bishops Terrace
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
4 Owner Owner's Name
information is
required for every Hyannis MA 02601 12-15-10
page. City/Town .State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 12
feet
Material of construction:
® cast iron ❑ 40 PVC Orangeburg
® 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: 6
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: 12
Distance from top of sludge to bottom of outlet tee,or baffle 20
Scum thickness
1"
Distance,from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
t5insp official document•OWN Title 6 Official Inspection Farm:Subsurface Sewage Disposal System•Page 9 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 70 Bishops Terrace
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Hyannis MA 02601 12-15-10
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 o7 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):
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I M 70 Bishops Terrace
Property Address
Bank Owned (Contact Daryl[ Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Hyannis MA 02601 12-15-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 70 Bishops Terrace
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Hyannis MA 02601 12-15-10
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.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1-1000 gal
❑ 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.):
Leach pit in good condition and empty at inspection with stain line at 20" below invert.
t5insp official document•03/08 Title 6 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
M 70 Bishops Terrace
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Hyannis MA 02601 12-15-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
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 Inspection.Form:Subsurface Sewage Disposal System-Page 13 of 15
- 1
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 70 Bishops Terrace
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Hyannis MA 02601 12-15-10
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.
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t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 70 Bishops Terrace
Property Address
Bank Owned (Contact Daryll Perry @ D.B. Enterprises 1-508-776-8916)
Owner Owner's Name
information is required for every Hyannis MA 02601 12-15-10
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: 20'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
t5insp official document-03/08 TrUe 6 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
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_ 5 12°34'30"W
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EXISTING CONCRETE PATIO
o EXISTING SEPTIC SYSTEM
I COMPONENTS 51OWN AS PER
PROPOSED I a,X 3G' 52 RECORD INFORMATION.
IN-GROUND
POOL o
DOORS TO BE EQUIPPED .
o WITH ALARMS
�o 0
W FENCE(4'MIN,)TO BE
EQUIPPED WITH SELF- -
LATCHING GATES. No.70
1('n In I STY.WD.FP'
b N N Cn 1
� z
APN 25 1-21 2
18,003±5F
proposed lot coverage: 10.2%
LOCI-15 15 NOT IN A SPECIAL
FLOOD HAZARD ZONE.
LOCUS 15 NOT IN THE s
WIND-BORNE DEDR15 ZONE.
L tP 145.00'
N I I°25'4G"E
BISHOPS (40'WIDE) TERRACE
BENCHMARK MAG NAIL 5Ei
EIEV.=50.00 (ASSUMEA)
I HEREBY CERTIFY THAT, TO THE BEST OF MY PROFESSIONAL
KNOWLEDGE, AND IN MY PROFESSIONAL OPINION, THE LOPCATION
OF THE PROPOSED SWIMMING POOL, AS SHOWN HEREON,
CONFORMS WITH THE HORIZONTAL SETBACK REQUIREMENTS OF THE
ZONING BY LAW OF THE TOWN OF BARNSTABLE.
51TE PLAN JOB No.: I G 14G
DATE: 070CT I G
IN
" =
BARN5TABLE HYANN15 MA SCALE: I 20'
PREPARED FOR
DAVID 5PRINGER
richard j. hood, p15
land surveyors - chill englneer5 `��oj2—
1 2 settlers path - 5andwlch - ma 025G3
Ph: 508.833.7100 - Email: rlkhood@cgmall.com
TROY WILLIAMS.
21 'L
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection (508) 385-1300
19 Hummel Drive
South Dennis, MA 02660 � ) �'4
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM F
PART A ECEIVED
CERTIFICATION
AUG 1 12003
ProperfN Address: 70 Bishops Terrace
Hyannis,MA TOWN OF BARNSI ABLE
Owner's Name: Karen Fitzpatrick HEALTH CREPT.
Owner's Address: C/o Kerry Fitspatrick
8 Colonial Drive,Duxbury,MA 02332
Date of Inspection:, August 6,2003
Name of Inspector: • Troy M.Williams O
Company Name: Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive -
South Dennis,MA 02660
Telephone Number: (508)385-1300
CERTIFICATION STATEMENT
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. 1 am a DEP
appro%ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sv,tem-
.�Passes
Conditionall%- Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: 8/6 163
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
Of system,piping or components. This inspection represents the conditions of the system on the Date of
Inspection noted above.
****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.
Title 5 Inspection Form 6/15/2000 pace I of I
Page 2 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
70 Bishops Terrace
Owner: Hyannis,MA
Date of Inspection: Karen Fitzpatrick
August 6,2003
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 CNIR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be placed or
repaired. The system, upon completion of the replacement or repair,as approved by the Board Health,will pass.
Answer yes. no or not determined(Y,N,ND)in the_ for the following statements
explain. not determined"please
The septic tank is metal and over 20 years old* or the septic tank(w tiler meta)or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is * minent. System will pass inspection if the
existing tank: is replaced with a complying septic tank as approved b e Board of liealth.
•A metal septic tank will pass inspection if it is structurally soun of leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break t or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settle r uneven distribution box.System will pass inspection if(with
approval of Board of Health):
ken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The sys required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspec ' if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner: 70 Bishops Terrace
Date of Inspection: Hyannis,MA
Karen Fitzpatrick
C. Further Evaluauoais Kelluire3d by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to detenmine if the system
is failing to protect public health. safety or the environment.
1. System Hill 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 envi nment:
_ 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 mar
2. System will fail unless the Board of Health(and Public Water pplier,if any)determines that the
system is functioning in a manner that protects the public healt safety and environment:
_ The system has a septic tank and soil absorption sys (SAS)and the SAS is within 100 feet of a
surface N%ater supply or tributary to a surface water s ly.
The system has a septic tank and SAS an. ie SAS is within a Zone 1 of a public water supply.
It
The s�-stem has a septic tank and S and the SAS is within 50 feet of a private water supply well.
The system has a septic tan - nd SAS and the SAS is less than 100 feet but 50 feet or more frortl a
private water supply well**. thod used to determine distance
**This system passes i e well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatil rganic compounds indicates that the well is free from pollution from that facility and
the presence of monia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure crite ' are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 70 Bishops Terrace
Hyannis,MA
Owner: Karen Fitzpatrick
Date of Inspection: August 6,2003
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
Nf, 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%a 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.
N e^ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
/,/9 Any portion of a cesspool or privy is within a Zone 1 of a public well.
NL Any portion of a cesspool or privy is within 50 feet of a private water supply well.
AtIg 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 coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and th resence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided1hat no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
AtO (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 will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a ign 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 systems in addition to the cri is above)
yes no
- _ the system is within 400 feet of a surface drin i g water supply
the system is within 200 feet of a tribu to a surface drinking water supply
the system is located in a nitrog sensitive area(Interim Wellhead Protection Area—1 WPA)or a mapped
Zone 11 of a public water su y well
if you have answered"yes"to question in Section E the system is considered a significant threat,or answered
"yes"in Section D above th arge system has failed.The owner or operator of any large system considered a
sigjeattt threat under lion E o;failed under Section D sha upgadsystem in accordance with 310 CMR
15.304.The system er should contact the appropriate regional office of the,Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
70 Bishops Terrace
Owner: Hyannis,MA
Date of Inspection: Karen Fitzpatrick
August 6,2003
Check if the following have been done.You must indicate"yes"or"no"as to each of the followine
Yes No
information was provided by the owner. occupant,or Buaid of I lealth
___.__ __✓ 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
Werr all system components,excluding the SAS, located on site
Were the septic tank manholes uncovered,opened,and the interior of the{pnk 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:
Yes no
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(3)(b))
5
Page 6 of 11
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL$YSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
70 Bishops Terrace
Owner: Hyannis,MA
Date of inspection:Karen Fitzpatrick
August 6,2003 FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): -9
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x a of bedrooms): 33o
Number of current residents: v ( t P': ).
Does residence have a garbage grinder(yes or no): .vo
Is laundn on a separate sewage system (yes or nu) yo [if yes separate inspection required)
Laundry system►inspected(yes or no): .v/,q
Seasonal use: (yes or no): mo
Water meter readings,if,available(last 2 years usage(gpd)): o,--d 3 3 2,o� f z
3 Sump pump(yes or no): nro e y
Last date of occupancy:
COMM ERCIAL/INDUSTRIA L
Type of establishment: _
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/per sons/sgft,etc.Y._
Grease trap present(yes or no):—
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 syst O•cs or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL, INFORMATION
Pumping Records •
Source of information:
Was system pumped as pan of the tnspe tion(yes or no): �y
If yes, volume pumped: _gallons-- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution 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)
—Tight tank _Attach a copy of the DEP approval
—Other(describe):.
Approximate age ofall components. datee installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): my
6
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
70 Bishops Terrace
Owner: Hyannis,MA
Date of Inspection: Karen Fitzpatrick
August 6,2003 ,
BUILDING SEWER(locate on site plan)
Depth belu%% grade: / 8 of+
Materials of construction: ,/cast iron 40 PVC_/other(explain):
Distance front pri%ate water supply well or suction line: A.19
Comments(on condition of joints,/venting,evidence ul leakage,etc.):
.O�c��D .. /vo
j". t5.ary
S t s C— t
r°rr►% � H,4pwho f 9 �/tC'
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: I
Material of construction: ✓oncrete_metal fiberglass_—Polyethylene
—other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Compliance(yes or no): .......(attach a copy of
certificate)
Dimensions:
Sludge depth
Distance from top of sludge to bottom of outlet tee or baffle: 2 ' 7
Scum thickness: NoAt�-- _
Distance from top of scum to top of outlet tee or batllc: Nu_5��...,
ffl
Distance from bottom of scum to bottom of outlet tee or bae: _
—.e.d
Ilow were dimensions determined: 11"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.):
}
0 r .k _s_�
N.—,�#.c w 4 s may./ ._�_.+_� ..✓c�}.._ t-.Q_�(_3. k.�t
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_fiberglass pdlyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or ba
Distance from bottom of scum to bottom of outlet a or baffle:
Date of last pumping:
Comments(on pumping recommendations • let and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of 1 age,etc.)
7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
70 Bishops Terrace
Owner: Hyannis,MA
Date of Inspection:Karen Fitzpatrick
August 6,2003
TIGHT or HOLDING TANK: (tank must be pumped at time of ins p ion)(locate on site plan)
Depth below grade:
Material of construction: concrete metal___fiberglass lyethylene other(explain):
Dimensions: - —
Capacity: gallons
Design Flo%%. gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working ord yes or no):
Date of last pumping:
Comments(condition of alarm and flo switches,etc.):
DISTRIBUTION BOX: 1�!/I(if present must be opened)(locate on site plan)
Depth of liquid level above 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.):
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,conditio of pumps and appurtenances,etc.):
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
j SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
70 Bishops Terrace
Owner: Hyannis,MA
Date of Inspection: Karen Fitzpatrick
SOIL ABSORPTION SYuSTt2003 SAS):( (locate on site plan,excavation not required)
If SAS not located explain why.
Type
,/ leaching pits, number: I - r; 'x C 'L„c ye �f �,,, &
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length: _
leaching fields,number,dimensions: _
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.):
!_ / ��-�`i..a .i'��_ b- o e- } u
Sly r� wak 10 3" 6t/oy.i- r`—`'ltr irr✓.�-lVo � �i a4 � c off'
A,4-- 1�.� c>f.^t l d j� r.S `p��-- 0�1 -A-. ) i S b r'te �,c�.,, y G ��✓�� �
CESSPOOLS: (cesspool must be pumped as Zneocate on site plan) �
Wo-v✓y1..�� ow
Number and configuration: `
Depth-top of liquid to inlet invert: c o��, j
Depth of solids layer.
Depth of scum layer. __
Dimensions of cesspool: ✓ s a- r.� �� �,; �,J r..
Materials of construction: S�-+ Au
Indication of groundwater inflow(yes or
Comments(note condition of soil,si 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 hydrauli ailure, level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 70 Bishops Terrace
Hyannis,MA
Owner: Karen Fitzpatrick
Date of Inspection: August 6,2003
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.
1000
`~ -
. zY
�" ,
3 q l
33
6')era 'Lc�L�p ,�
10
Page l l of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
70 Bishops Terrace
Owner: Hyannis,MA
Date of Inspection: Karen Fitzpatrick
SITE EXAM August 6,2003
Slope J
Surface water
Check cellar ✓
Shallow wells
Estimated depth to ground water 3$•o feet Adjusted high ground water elevation .3S.tfeet
Please indicate(check)all methods used to determine the high giuund slater elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
—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)
s/ Accessed USGS database-explain: _4 I� 3.°
You must describe how you established the high ground water elevation:
�1 4- t t sy U �a /� ✓`'`C--`^�` <,!. w. ..�. v j G.1 V 'h s t�cY --(t _S L. a __�s.3_✓H
r Lfr
✓V V
' I
a �
This report has been prepared and the system inspected as of the date of inspection. This report is not a
warranty or guarantee that the system will function properly in the future. There have been no warranties or
guarantees,either expressed,written or Implied,relating to the system,the Inspection and/or this report.
11