HomeMy WebLinkAbout0041 CHESTNUT STREET - Health I
{ 41 CHESTNUT ST. , HYANNIS
A = 309 116
TOWN OF BARNNSTA13LE
LOCA*11ON ST SEWAGE
VILLAGS / � ,�/G n n S As"SESSOWS r W&LOT
WSTAt t "R'S NAME&PHONE NO.
Ssmc TANK.cAPAcITY /5 Cb c
L6ACHII+iG f+ACELITY: ( ) C�G"• -e.-S (size)
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NO.OP'B6DROOMSJ/
BUILDER OR OWNER
pERA/diTDJATE: CpM'LlR►1�10E DATE:._....
Separation Mtance Between tape:
Maximum Adjusted,GrouudwaterTabla to the Bottom of Leaching Facility
Privoe yVaor Supply VICH asld if eachiag Paciiity (if arty wells exist Teo9
cis site or within 200 feet of laachi%facility)
F.cl,p of Wetland and Leacbing Facility(U any wetlands exist
Feel
within 300 feet YeAebing facility)
ftnishod by
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y 1� _TOWN OF BARNSTABLE
LOCATION`?� C l�' ` L/Lt. ` SEWAGE # &1D-0
VILLAGE ASSESSOR'S MAP & LOT /47
=d,INSTALJ,ER'S N &PHONE NO. �'��
SEPTIC i ANK CAPACITY
LEACHING FACILITY: (type) gl-— t�'o`' (size) /69-0�u
NO.OF BEDROOMS
BUILDER OR OWNER C--" i9? eC 0451W
PERMITDATE:40--;�1, S vZ&0-e COMPLIANCE DATF, �
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Le hing Facility Feet
Private Water Supply Well and Leaching Facility (If y wells exist
_ on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If anyetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts
w. Title 5 Official Inspection Form
�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r.
41 Chestnut St
Property Address h a
Peter and Susan Campbell M;
Owner Owner's Name
information is +
required for every Hyannis MA 02601 4-13-18 x?
page. City/Town State Zip Code Date of Inspection f.�b
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.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 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 15.006).The system: '
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further E the Local Approving Authority
4-13-18
I spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
I
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
iwl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Chestnut St
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,C, 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 describes
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.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tanks 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
Title 5 Official Inspection Fora
�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Chestnut St
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
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 El ❑ 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 ON ❑ ND (Explain below):
❑ obstruction is removed ❑Y ON ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1: System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i� w"
} �'Q Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Chestnut St
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
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 andif 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
❑ ® 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
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
r� Title, 5 Official Inspection Form
I,I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Chestnut St
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No t
❑ ® 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.
El Z Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion-of,a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. (This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd. . 4
❑ ® 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
r� Title 5 Official Inspection Form
�w�'
nl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Chestnut St
J-
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
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?
® ❑ Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation o;distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
a Title 5 Official Inspection Forts
6 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Chestnut St _
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
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? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 4-2018
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
cam° Commonwealth of Massachusetts
y Title 5 Official Inspection Form
., :
bl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Chestnut St
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
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--pumped 3yrs ago
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for um in :
p p g
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
t Commonwealth of Massachusetts
y Title 5 Official. Inspection Form,
} -I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Chestnut St
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) ,
Approximate age of all components, date installed (if known) and source of information:
2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan): O
18"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: Years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gal
Sludge depth:
12"
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
�-f'
Title 5 Official Inspection Form
ill Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�It z i�t, i F01'
41 Chestnut St
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
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
20"
Scum thickness
1"
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
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: -
Date
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
r ,w Title 5 Official Inspection Fora
i-lt Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Chestnut St
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
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.):
Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: bate
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
c Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
'l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°1 41 Chestnut St
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
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 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box., etc.):
Good condition with water at working level and no sign of back-up from field.
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
? YI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Chestnut St
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2-500's
❑ 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 chambers in good condition and holding 6" of water with no visible stain lines.
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
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r T, ` 41 Chestnut St
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
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 Disposal System-Page 14 of 17
Commonwealth of Massachusetts
r� ,w Title 5 Official Inspection Form
i i41 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Chestnut St
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
—
page. City/Town 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
01
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
c Commonwealth of Massachusetts
3 Title 5 Official Inspection Form
wa
I�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
:.JJ 41 Chestnut St
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
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: 12
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:
Original design plans show no groundwater at 12'.
g g P
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
L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Chestnut St
J
Property Address
Peter and Susan Campbell
Owner Owner's Name
information is required for every Hyannis MA 02601 4-13-18
--
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc-rev.6116 Title 5 Official Inspection Form;Subsurface Sewage Disposal System-Page 17 of 17
w
No. / , Fee 5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYicatiou for Migool *p.5tem Com5truction 3permit
Application for a Permit to Construct( )Repair(( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Iigcatl,Yl
ioeS nu1N Jt . , Hyannis OP9e serme�t�s�Ii ftbell
Assessor's Map/Eucel
Installer's Name, dress,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Roinson Septic Service
P 0 Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil S and.
Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system, consisting
of tank D-box and. 2 leach chambers),with stone all around..
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued bythis-.Poarof Health. f � �
Signed 4 Date / y
Application Approved by e Date ` "
Application Disapproved for the following reasons
Permit No.R 46,440 Date Issued
• No. 07 0101 "° � Fee �5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
�__.•_ _ Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
01ppYication for Mi5paar *paem Conztruction Permit
Application for a Permit to Construct( )Repair(K )Upgrade( )Abandon( )a❑Complete System El Individual Components
1"°6fie s nu%NoSt. , Hyannis
Assessor's Map cel
Installer's Name, dd;ess and Tel. o. Designer's Name,Address and Tel.No.
Wm. E . Robin SNeptic Service
P 0 Box 1089, Centerville
Type of Building:
Dwelling No.of Bedrooms 3 Lot Si e s .�� Garbage Grinder(' )
' Other Type of Building No.7Ferso s Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand. r ;�
Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system, consisting
of tank, D-box and 2 leach chamber�.,.with stone all around .
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by�thli�s_ -�, f(Health.Signed ../
Date
Application Approved by Date
Cy
Application Disapproved for the following reasons
Permit No.,?f-# *A :Z e Date Issued /-W '" I
---------------..,yam----------------=--------
THE COMMONWEALTH OF MASSACHUSETTS
Campbell BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (X )Upgraded( )
Abandoned( )by Wm. E . Robinson Septic Service
at 41 Chestnut St . , Hyannis has been constructed in accordance
with the provisions of Title 5 and the for Disposall Sy Construction Permit XV 00.4 dated Z f
Installer Wm. E . Robinson Sr? ¢ ,f / Designer
The issuance of this permit shag not be ufd(.a&.a gh an`�ee that`Yhe systt m will function as desi neg
Date G I / Inspector /d M / � J
No. a�"-4`,f0I� '`°'' ,�/F,� --------------------------Fee e �p
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Campbell migool *pttem Construction Permit
Permission is hereby granted to Construct( )Repair(X)Upgrade( )Abandon( )
System located at 41 Chestnut t b , Hyannis
i
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: .' Q Approved b se.•a e�" .� '`�
PP
r
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, William E . Rob ins on,SAereby certify that the application for disposal works
construction permit signed by me dated 1",� 0 �- , concerning the
property located at 41 Chestnut St . , Hyannis meets all of the
following criteria:
The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
VThe soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
'
ere are no wetlands within 100 feet of the proposed septic system _
�Altere are no private wells within 150 feet of the proposed septic system
V ere is no increase in flow and/or change in use proposed
ere are no variances requested or needed.
• e bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation: f Adjust the groundwater table using the Frimptor
method when applicable]
If the S.A.S.Nvill be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
) G.W. Elevation _ +the MAXMA High G.W. Adjustment
DIFFERENCE.BETWEEN A and B
SIGNED : l DATE:
[Sketch proposed plan of system on back].
y:health folder:cen
.�
\ ��
C�S
a
__
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.-
_TOWN OF BARNSTABLE ,4
LOCATION 1tiL7 SEWAGE #
j VILLAGE ASSESSOR'S MAP & LOT
i
j INSTALLER'S N &PHONE NO. ��b /�'�d fit• ' ?�f �„ "' u
4
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) �Z —S"" (size)
✓ NO. OF BEDROOMS /
BUILDER OR OWNER G<' W7 Wk6 ll
PERMIT DATE:�7�11 COMPLIANCE DATES
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Le
aching 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 anyetlands exist
i
within 300 feet of leaching facility) Feet
. � Furors y
Furnished b
i
I
I� r
r
-LOtCAT ION SEWAGE PERMIT NO.
VILLAGE
�ti
�A N NbNS Zry C S M A '\AI �=
I N S T A LLER'S NAME & ADDRESS
B U kL D E. R OR OWN ER
Ll I lg77
DATE P RMIT ISSUED
DAT E COMPLIANCE ISSUED
� --` 3�!
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o
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2
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C, 1�11otl C/
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No...... .... F�s...J�... ....
THE COMMONWEALTH OF MASSACHUSETTS
BOA R.D F H E LTH
,;
Appliration for Disposal ,arks C� n`n' 'itrn.rtinn rumit
Application is hereby made for a Permit to Construct ( . ) or Repair (')() an Individual Sewage Disposal
System at: i
..... ................ -------------------------------------- ---••--•--•-•-••-•....---.....----•--•----. ---------•-•-------------•---•-----....•.
Location-Addres
or Lot No.
Owner Add ress
a C.Aq-N.!�:LA........JAL:.--------•-------------------•---•--------- .........`.......................................................................................
Installer \ Address
Type of Building ` Size Lot----------------------------
Sq. feet
�. Dwelling�C No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Buildin
a yp g ____________________________ No. of persons............................
Showers ( ) — Cafeteria ( )
d . Other fixtures
W Design Flow............................................gallons per person per day. Total daily flow---_•-___....___--_..___--------------------
gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.........._---------sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( -) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water...................
04 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ......----•---• � --•-.-•-• ••••.••---••-••-••••-•••••••----••-•--....
Description of Soil.................... .�d
x ,
U ••-••-••••••••••••••-•-•-••••---••••-••--••-•--••••-••-••••••••-••--••-••-••--••••••••--••••••-•-••••••••.....••-•••••••-••-•---•••••••••••------•-••••-•••--••-••••••••••........................•••••.
w _x •••••••-•-••-----------------------•--••••••----•-•----•-•-•---••-••--•--------••••-•._..••••-••••••---•--••••••------------••••--••••-••......••-••-•-•--•......••• ---...
U Nature of Repairs or Alterations—Answer when, applicable,�L �..�.l I/ --•-Q-E....ASP - N L-------------
--•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLI, 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss I b the b rd of *"alth.
Si we --•-•--••••-•••••.....•• 1t.:7/
.::
Application Approved By..... _ .................. � J
Date
Application Disapproved for the following reasons:-------•---------------------------•----•--------------•---•-------•----------------...........................
...............••••••-•••••-•••••-•--••••-••-•--•-•-•••••••...----•-••-••••---••--••---•-..._..•••---••--••-•••--....-••••••-••••-•••••••-••••••••....................................................
Date
PermitNo......................................................... Issued.......................................................
Date
/
77
No......_"....f... ....... Fim... .......
`�2--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H ALTH
........ J' '."."........_OF......
ApV ira iun for UiipmFal 19orks Tonotrnrtion rrruti#
Application is hereby made for a Permit to Construct ( ) or Repair ()( ) an Individual Sewage Disposal
System at:q _
( C�,- �+
......... ....__. .._.---.......---...---•--•----.....-----•-•------•••--•---._............ --•--•----------------•---•-•------••--------• •--........
Location-Address or Lot No.
J....................... A. c...............
Owner Address
Installer Address
Q Type of Building Size Lot............................Sq. feet
V Dwelling✓_No. of Bedrooms............................................Ex Expansion Attic— p ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Otherfixtures .---------•----------_- ---------•--•-------------------•-•-••••-•------•-------•-•------••--••---•----•-•••----•-•••••-••-...-•-••-••.......---
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth.................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
tz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
---------------------------------------------------•---•------------------------.....--•---..................................................................
0 Description of Soil-------------------------------------------------------------------- ----------•---------------------•----------- .....................................................
x
U --•••-•--•---.._...••----•-••--•---.....----•••••--•••••-••-•-•-••-•-•--•-•----•-••-•--------•-•----••••-•--•--------••••-•-••••-•-------•••---••--•---••-•-•-------•-....•----•......-•..............•-
UW ••--------•--------•---•----•--•••--•...--- ----•-------------•----------------•-•••-•••••••------•---••---••-•-------------.....--•-•-----•-•--•••---•--•-••••--•••-••--••-•------•••--•-----•-•--_...
Nature of Repairs or Alterations—Answer when applicable.-O_5.1--L+!=<:t ! !r_ o% Ai-4-1 f '01 r n
�ccc G r_LCli I`( (.I
---------------------------------------•-----------------•--------•-----------------•--....-•--------------•------------------------...----------------------------------------------...------•....•...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI.t�. 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of,health. ff�'
jSigne ==...............................................................frf).` ,�i�r '
. -•-- --•• ----•---
J'W
Application Approved By.....,r_ .. ...L....... lN�. ---------------------•--...... e '�7
V Date
Application Disapproved for the following reasons------------------------------------------------------------------------------------------------•-•••--....•.....
-•...............................•-------..........-•--•••-••----••-.......----•--•._.......-•••----.......
----------------•-
Date
PermitNo......................................................... Issued•.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
.........7A -
r �.......OF.......... . .....�...................-----------.........
C rr ifiratr of ToutpfiFatta
T,V'I-,S IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( vf) or Repaired ( )
- :........ ----------------------- -
Y // j J Installer
i
at. `..7e has been installed in accordance with the provisions of 'I- L �5 o The State Sanitary ode as Described in the
application for Disposal Works Construction Permit No------------------ ................ dated--........1.':..�-.Z..................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL F NCTION SATISFACTORY.
DATE.......... ' .....( Inspector ---------------------- f----••---•-__-••. +
THE COMMONWEALTH OF MASSACHUSETTS
BOARD F HEAL
7
No...................... FEs........
Diopo €l Workg Tons udion Vrrmit
Permission js-hereby granted--- f. ..--.- )/1 = ---------------------------------------------•---------....................
to Construc� ( ) rd-p Repair ( ) 2'n4Individual Sewa spos, Systr()
� f_............................................ .................................. .h.................................................
Street
as shown on the application for Disposal Works Constructio Pvinit/'No....... Dated. . /._ _? ...............
DATE.......--•-•-------------..../--•------......................................... Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS