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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is required for every HYANNIS MA 02601 12/18/2014
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer, ------
use only the tab ti T
1. Inspector: rl��key to move yourUcursor-do not JOHN P GRACI SR (
use the return key. Name of Inspector
GRACI SEPTIC INSPECTIONS LLC
r� Company Name
PO BOX 2119
Company Address
TEATICKET MA 02536
City/Town State Zip Code
508-641-6694 S1468
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation the Local Approving Authority
l� 12/18/2014
Inspector's Signature bate
The system inspector shall sub a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 day completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd 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.
U6Ad1
t5ins•3/13 Title 5 Official In cti Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M
169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is HYANNIS MA 02601 12/18/2014
required for every
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
SYSTEM PASSES TITLE V INSPECTION
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
NA
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is required for every HYANNIS MA 02601 12/18/2014
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
NA
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
NA
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is required for every HYANNIS MA 02601 12/18/2014
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance: NA
** 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:
NA
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is required for every HYANNIS MA 02601 12/18/2014
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water,supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well:
❑ ® Any portion of a cesspool or privy is less than 100,feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is required for every HYANNIS MA 02601 12/18/2014
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
® ❑ approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is required for every HYANNIS MA 02601 12/18/2014
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
1000 GALLON H-10 SEPTIC TANK, NEW- H-10 DISTRIBUTION BOX AND 5 INFILTRATORS 37'
X 10'X 1' PER ASBUILT
0
Number of current residents:
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)):
TOWN
Detail
2013 10900 CUBIC FEET 2014 6800 CUBIC FEET
Sump pump? ❑ Yes ® No
MAY 2014
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
NA
Type of Establishment:
based on flow Design 310 CMR 15.203 : NA
9 ( ) Gallons per day()pd)
Basis of design flow(seats/persons/sq.ft., etc.): NA
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: NA
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is required for every HYANNIS MA 02601 12/18/2014
-
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: NA
Date
Other(describe below):
NA
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: NA
gallons
How was quantity pumped determined? NA
Reason for pumping: NA
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is required for every HYANNIS MA 02601 12/18/2014
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:
2004 LEACH FIELD SEPTIC TANK1979
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 18 INCHES
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: GREATER THAN 10+'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: (2)TWO FEET
p g feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: NA
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: STANDARD 1000 GALLON H-10
Sludge depth: 10 INCHES
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is required for every HYANNIS MA 02601 12/18/2014
page. Citylfown 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 (2)TWO FEET
Scum thickness (4) FOUR INCHES
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
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 APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT
TIME OF INSPECTION. UNABLE TO INSPECT UNDER NORMAL USEAGE. RECOMMEND
PUMPING EVERY TWO YEARS.
Grease Trap (locate on site plan):
Depth below grade: NA
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
NA
Dimensions: NA
Scum thickness NA
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
Date of last pumping: NA
Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c°M 169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is required for every HYANNIS MA 02601 12/18/2014
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.):
NA
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
NA
Dimensions: NA
Capacity: NA
gallons
Design Flow: NA
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: NA Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
NA
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is HYANNIS MA 02601 12/18/2014
required for every
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 BOTTOME OF PIPE
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.):
H-10 DISTRIBUTION BOX APPEARS TO BE FUNCTIONING PROPERLY AT TIME OF
INSPECTION. UNABLE TO INSPECT UNDER NORMAL USEAGE.
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.):
NA
* 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:
NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is required for every HYANNIS MA 02601 12/18/2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 5
❑ 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.):
5 INFILTRATORS ( 37'X 10'X 1' PER TOWN) APPEARS TO BE STRUCTURALLY SOUND AND
FUNCTIONING PROPERLY AT TIME OF INSPECTION. UNABLE TO INSPECT UNDER NORMAL
USEAGE. EMPTY AT TIME OF VIDEO INSPECTION.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
Depth—top of liquid to inlet invert NA
Depth of solids layer NA
Depth of scum layer NA
Dimensions of cesspool NA
Materials of construction NA
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is required for every HYANNIS MA 02601 12/18/2014
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.):
NA
Privy (locate on site plan):
Materials of construction: NA
Dimensions NA
Depth of solids NA
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
N f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is HYANNIS MA 02601 12/18/2014
required for every
State Zip Code Date of Inspection
page. City/Town
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
PrA 21
A6 25 ''
At 2q
DEck
�C OU
A
O
4
r
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 15 of 17
Commonwealth of Massachusetts
y Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is required for every HYANNIS MA 02601 12/18/2014
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: 10+ FEET
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed:
❑ 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:
HAND AUGER
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins•3111 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
169 COMPASS CIRCLE
Property Address
FRANK PACITTO
Owner Owner's Name
information is required for every HYANNIS MA 02601 12/18/2014
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
169 Compass Ct�cl e-
?rerty Address
Du ntry wide ICED �'(C�rlCett nct ���"`'t off"
Owner 0 Mnnni�s
' Name
information is M�
required for
every page. City[Tclwn 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. In actor:
i c I L \/`1 r i -t
Name of Inspectors r—
ra Fyrrivn+inn
Company Name
Com any Address
o�e��caQl>° MA �b r
Cityrrown State Zi Code N
5o8 . 111 7- 0G5 3 5 I 5 9-1
5-'-
Telephone Number License Number
� vy 14 -7
B. Certification 1
1 certify that I have personally inspected the sewage disposal system at this address and that the
infofmation 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 C:'!3/1/0 CMR 15.000).The system:
Passes ❑ .Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Insp9 or'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.
tSlnsp.doc-03/08 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 15
7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
� I C 9 Compass A rr-► -e
Property Address
Coun+r�v�tG��
Owner Owners Name —
information is N MA V 2(o U i 1 -Z d
required for
every page. Cityrroskn 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:
UKI 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.An failure criteria not evaluated are
indicated below.
Comments:
IF
B) System Con itionally Passes:
❑ One or more ystem components as described in the"Conditional Pass"section need to be
replaced or re aired.The system, upon completion of the replacement or repair, as approved by
the Board of He Ith,will pass.
Answer yes, no or not termined (Y, N, ND)in the❑for the following statements. If"not
determined,"please exp in.
❑ The septic tank is meta and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, ex 'bits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspecti if the existing tank is replaced with a complying septic tank as
approved by the Board of alth.
*A metal septic tank will pass i pection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the nk is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or hig static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,s ttled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
t5insp,doc.03108 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
Property Address �
Courn-trvwirle ?\'F/) 4�c F��a
Owner Owneg Name If J
information is
required for U Q n n 1 IS "l
every page. Cityrrown 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 p ping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspectio if(with approval of the Board of Health):
❑ broken pipe(s)are rep ed
❑ obstruction is removed
ND Explain:
C) Further Eval t!on is Required by the Board of Health:
❑ Conditions exist ich require further evaluation by the Board of Health in order to determine if
the system is failing protect public health, safety or the environment.
1. System will pass u ss Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the sys m is not functioning in a manner which will protect public health,
safety and the environmen
❑ Cesspool or privy is wit ' 50 feet of a surface water
❑ Cesspool or privy is within feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board Health (and Public Water Supplier, if any)
determines that the system is function gin a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil a orption system(SAS)and the SAS is within
100 feet of a surface water supply or tributa to a surface water supply.
❑ The system has a septic tank and SAS and th AS 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.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
° 16, 9
Comonss Ci t-G( e
Prope Address
Nun+(-
Owner Owner' me
information is
required for -a D a n i s M Ud
every page. CityfTown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation ' Required by the Board of Health (cunt.):
❑ The system has a s tic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private ter supply well'".
Method used to determine istance:
**This system passes if the well wat analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the pres ce of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other ure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
i
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
ElBackup 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.doc•03108 Title 5 Offic al Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
°~ � Co 9 n__mPnss CI r�l
Property Address
Cvun VQIA CL r—V— +t n o
Owner Owners Name
information is 1 1�/-I n n I s ► 1 A-
required for 1� `��
every page. City 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.
❑ L3/ Any portion of a cesspool or privy is within 50 feet of a private water supply
/ well.
❑ I� 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.]
❑ 12/ The system is a cesspool serving a facility with a design flow of 2000gpd-
10'000gpd.
ElE / 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
desig flow of 10,000 gpd to 15,000 gpd.
For large stems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions i ection D.
Yes No
❑ ❑ th ystem is within 400 feet of a surface drinking water supply
❑ ❑ the syste within 200 feet of a tributary to a surface drinking water supply
❑ the system is Ioca in a nitrogen sensitive area(Interim Wellhead Protection
El Area—IWPA)or a ma d Zone II of a public water supply well
If you have answered"yes"to any question in Secti E the system is considered a significant threat,
or answered"yes"in Section D above the large system as failed. The owner or operator of any large
system considered a significant threat under Section E or iled under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system ow r should contact the appropriate
regional office of the Department.
t5insp.doc•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
ComPC-1s ccl �
Property Address
Coynt�Y�;`if�e �Fn ark. + ��l.G
Owner Owner's Name '
information is H (1
required for
every page. Cityrrow 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?
Q/ Have large volumes of water been introduced to the system recently or as part of
El 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?
ere the septic tank manholes uncovered,opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
❑ Existing information. For example,a plan at the Board of Health.
❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
t5insp.doc-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
� 6 9 ro m DO GS i re,l
Property Address
o ntr v.( ►c! RED +t
Owner Owner's Name
information is
required for H V n n n I N pz6 -7- 2. - b
every page. CityrrowA State. Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): eS. Number of bedrooms(actual): — •—
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): I?p 6. `
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes D-No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ElAo
Laundry system inspected? ❑ Yes E/No
Seasonal use? ❑ Yes �o
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump? ❑ Yes QjAo
Last date of occupancy: Date
Commercial/I ustrial Flow Conditions:
Type of Establishme
Design flow(based on 31 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/per ns/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 s tem? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5insp.doc•03= Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Off J00 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
° CDfYln��SS Ct r�-1 �.
Property Address IF
CDUni rvwld e PF CLr-Le-� L(�Q
Owner Owner's Name
information is dz 6O 1
required for -I vn n n i s �
every page. Cityrr04 State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping R cords:
Source of informs'on:
Was system pumped a art of the inspection? ❑ Yes ❑ No
If yes,volume pumped: gallons
How was quantity pumped determin ?
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:
Were sewage odors detected when arriving at the site? ❑ Yes o
15insp.doc•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
IC9 Comr)Ass LI-de.
Property Address ,
Co I)ni-rVWiAt�Fo
Owner Owner's Name
information is (.I �Q n n( S MA 0,k L o I z required for f l t _����'�
every page. Cityrrowh State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan): /
Depth below grade:
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.):
>m/a t5 TT' W e
Septic Tank(locate on site plan):
Depth below grade:
feet
Material of construction:
2-sencrete ❑ 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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle Cl
Scum thickness
y
Distance from top of scum to top of outlet tee or baffle
i •
Distance from bottom of scum to bottom of outlet tee or baffle 3
How were dimensions determined? 'M e>v���
t5lnsp.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
WROM Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
Owner D 1)n+C V W t �' C1
Owner's Name
information is
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquid levels as relate/d/to outlet invert,evidence of leakage, etc.): / p
�. l I t f/ I,A( t 1056 ( Gt G oR f IM G
1/1 S22yn6fn
Grease Tra (locate on site plan):
Depth below gr de: feet
Material of const tion:
❑concrete metal ❑fiberglass ❑polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top o utlet tee or baffle
Distance from bottom of scum to botto f outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inle nd outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of kage,etc.):
Tight or Holding Tank nk must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
Elconcrete El metal XE
ss ❑ polyethylene ❑other(explain):
t5insp.doc-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
1� 9 C2m �cs� C► ��l-e
Property Address
Co Ur-+rv,,,,ttd~°
Owner Owners Name
information is I� o i S MA 07,601
required for
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Viol 'ng Tank(cunt.)
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 \floathes, etc.):
*Attach copy of current pumping contract(required). Is py attached? ❑ Yes ❑ No
Distribution Box(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.):
/� Cyr/►� C�e� d.- ���K�ts�_
Pump Chan
r(locate on site plan):
Pumps in working orde . ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp.doc•03108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
1 ( 9 Cornoriss Irrie
Property Address If
Co0n+r 16 e. nrb--+ knQ
Owner Owner's Name
information is
required for H - p 26d1
every page. CityfTowA State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of ump 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:
❑ 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.)f :Y►�S�G�t�' l�`►,n5 �fr.'P/�G` f��/17�`i /JP/!B' /a/'y�
I `G l it L—c6 52!C29M., _6604 G✓�i j i+e
S�•>a � fi�ok �p
a..
t5insp.doc•03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 15
I
A
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Property Address
CDun+r \,/ , oAf-. Eb ar•ke In
Owner Own r' �Name
information is
required for Q /Q n r11 S M A C)
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number an configuration
Depth—top of li id 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 hydra 'c failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site an):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, sig of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•03108 Tllle 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
9 Cl) PI)ss Clrc� �
Pro erty Address 00nic -R1_GG
d c-L l
Owner Owner's Name '
information is
required for
every page. City/T�nro1 t— 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.
1 1
A)
►3�= 3 f C�
t5insp.doc•03108 Title 5 Official Inspection Forth: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
1 Coq C,omPC1c CtrLl-�
Property Address
Owner Owner's Name
information is MA-
every
required for
page. Citylr n State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
heck Slope
Surface water
heck cellar
Shallow wells
Estimated depth to high ground water:
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 � T'° /
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
15insp.doc-03108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 15
Town of Barnstable
Regulatory Services
BARNMBLE. : Thomas F. Geiler,Director
9� 1639. 1�g'
pTEo3�a Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number
of bedrooms approved 'at a particular property would be listed on the "Disposal Works
Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIC\Disclaimer Private Septic Inspections.DOC'
a
TOWN OF BARNSTABLE
LOCt�- IOTl 1L!AC-d V4160' W C�� SEWAGE
VILLAGE ASSES (R'S MAP & LOT70—� �
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY ���5 1`'Y� c�/ � �
LEACHING FACILITY: (type) (size) c �r�Id(� , f
NO. OF BEDROOMS
BUILDER OR OWNERS
PERMIT DATE: 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 33000,feet-of-leaching facility) Feet
Furnished by
CZ9-1
� 1
r
® ® 1
`N
1
y
Fl
t
No. �C/ FEE \.J�
COMMONWEALTH OF MASSAC14USETTS
c
Board of Health, MA.
APPLICATION FOP, DISPOSAL SYSUM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System Xndividual Components
i
1
Location Owner's Name d
Map/Parcel# Address
Lot# Telephone#
Installer's Name O Designer's Name
Address Addres �q A
Telephone# e., Telephone# t
Type of Building ,�� Lot Size I sq.ft.
Dwelling-No.of Bedrooms tNM c
Garbage grinder ()WA
Other-Type of Building No.of persons a _Showers ( Vafeteria (v�,
Other Fixtures
Design Flow(min.req Calculated design flow Design flow provided s2j&1.8 gpd
Plan: Date C>A- Number of sheets 1 Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator rnnox�Sb;6Date of Evaluation 0
DESCRIPTION OF REPAIRS OR ALTERATIONS Ogg
i
The undersigned agrees to ins the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
furth oft I e,the t operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
v t^
'�r''��k.t.:;�6+"a'1,d�,,..^......5%�r.L�•..r:•-'�,.,;,,d'tys�F'�..':.rd'e...�'',,,r`�/�.+�.*,,,C`a�, �"'�r.i'dy"'+.'.�iYr�;,w...�jp.'"`cr"'r`r7' ,�e�sy.�.,,..�;�.s..�^.i+-.w;f✓4 . . 1-
FEE 7
Comm NWEALTH OF MASSACHUSETTS
Ci�3�'. MA.Board of Health, C1 V
- P
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repa�(�UpgradeO Abandon( ❑Aomplete System dividual Components
Location Owner's Name
c Map/Parcel# �,(� � ,�.}al�• � Address
4 - '
Lot# Telephone#
Installer's Name c Designer's Name
Address I
Address
.5 c- k � ra r.�► sR c :�x E nw+ 1m t
..
Telephone# ( { _ ! Telephone# LA 8—[-� 91-0
Type of Building ^,� �.( \ //*� Lot Size sq.ft.
Dwelling-No.of Bedrooms "` io�C) l � Garbage grinder (A/Ifs
Other-Type of Building (\ T No.of persons c Showers ( 01�Cafeteria (�
Other Fixtures t'2,\^1��'af'� St.(lk�
"at
Design Flow(min.required)w c -Q � gpd Calculated design � e-) Design flow provided ��_It 2) gpd
Plan: Date —' C)4 Number of sheets { Revision Date
Title `! CXtic_ ?Cl� 521 �,C
Description of Soil(s) �
Soil Evaluator Form No. N e.bf Soil Evaluator 1 e' Y isr,�hcs�1Date of Evaluation 4 1 10 4
1t
..DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agre"es-to,not t(o;;pla e�system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed Date
p j/Jy7 //
v l/� f v
3
FEE
c� s
Board of Health, 1�c�r, r• �.t MA. ` e
CERTIFICATE Of COMPLIANCE
Description of Work: K> Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired,,0<Upgraded ( ),Abandoned ( )
at 1 Gq V h tri-en�.r_: n,C7_0^0 ci t-i.-u Q nr-% -C NA A
has been installed in accordance with the provisions of 310 CMR 15 00 (Title 5)land the approved design plans/as-built plans relating to
-
application No. ) L dated '-G7 1/ JY i Approved Design F1owE . (gpd)
Installer V �` x�-- S f>yt ��•� Q`ll C'�F
Designer: 4 k5 (4Y -1",0lCcanerv�eV �C1 Inspector: /� ► �L�6�^--- � — Date: �lttt�"
-,
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
r ,
No.• App-," FEE
COMMONWEALTH OF MASSAC14USETTS
Board of Health, r �e�.��s� MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair,>< Upgrade( ) Abandon( ) an individual sewage disposal system
at \V62S Cam)0W�->S C> k-\,A �ti� r`-'1 A as described in the application for
% - V 4 ,
Disposal System Construction Permit No. dated
Provided: Construction shall be completed wilhinn three years of the date of diis�permi't. A-111 local conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date 6117�i1 ,/✓ Board of Health
TOWN OF BARNSTABLE
LOCATION � � �rG� SEWAGE * 1P
VILLAGE `G1-�G � ASSES R'S MAP& LOT WkQ -H�— .
INSTALLER'S NAME&PHONE N0 �,v
SEPTIC TANK CAPACITY -At
�"�' ��' C�/7LEACHING FACILITY: (type) ca '�[ (size)7 7')!CfCOt r
NO.OF BEDROOMS
BUILDER OR OWNER �O�
PERMTTDATE: COMPLIANCE DATE:
Separation bistance Between the:
Maximum Adjusted Grou3vvatter 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
Furnished by
r
o lj
o
1 ^
��t L
�/ J
Town of Barnstable
oFIME r°w Regulatory Services
do
Thomas F.Geiler,Director
* BARNSFABLE,
MASS. Public Health Division
i639•
ATFoA Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: 2=A 17, 01-
Designer: 'SAgq 'Sk-S Installer: �bQP �� e
Address: Address: �fs =s"p0AM0 ;
On was issued a permit to install a
( ate)) (instal er)`—
septic system at SS tom,L_ based on a design drawn by
address)
dated I� i
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
N�H OF bfgS0,
c
CARMEN GN
(Installer's ignature) E.
a SHF:Y
No. 1181
�F o
- orsTE�t;
(Designer's Signature) (Affix Desigif&4Q&D Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
Sp-p - 20- 01 13 : 52 BARNSTABLE HEALTH DEPT 5087906304 P . U2
SRSiQI
!NOTICE; This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
PERCOL,sMON 'PEST AND SOIL EVALUATION EXEMPTION
FORM
hereby certify that the engineered plan signed by me
;!a;ec —, 04' , concerning the property located at
S P., JA r�,t, meets all of the
E
f,I:ow;ng c�,teria.
• This failed system is connected to a residential dwelling only. There are no
.ommztrzia.1 or business uses associated with the dwelling.
• 7'.e soil is ciass:;ied as CLASS I and the percolation rave is less than or equai t0
-nmutes pet inch. The applicant may use historical data to conclude this fsc: or may
..oncuct tests at the site without a health agent present
• There :s no increase In flow and/or change in use proposed
• There are ;to variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than fourteen
aoove the maximum adjusted groundwater table elevation. (Adjust the
;rnunc!wa,,er table using the Frimptor method when applicable)
Please complete the following:
fop of Grounc? Surface Elevation (using GIS information) _AA-uo
J, ( -VY E!Cvat:on adjustment forni,h G.W. &S = •50
�TFF..R,Ei\,CF BETWEEN , and B
S G.VE D __. D ATE.
NOTICE
33sec a-on tine a,ove rformacion, a repairpermit will be issued for �edr^om.s
bedrooms are authorized to future without en;tncered
epl,. syaern plans. __—.--
i
�rtun!r,:aci Pciccam7
Permit Number: Date:
Completed by:
HIGH GROUNDWATER LEVEL COMPUTATION
Site Location: ` cinQO.tl (fgAg MSS MA Lot No,
Owner: �'p�n (1�- Address: 1�cb
Contractor: 1r-Jh ,Q_V ► Address: �C3��'M �tA 1�r
Notes: ` \�S� V S�k uw
STEP i Measure depth to water table 2T
tonearest 1/10 ft. .............................................................................. .Date 4 3a
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate ��t-�1-a3o
site and determine:
OAppropriate index well.................................................... 4"
OWater-level range zone ..................................................... C
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ...........................
mon h/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 2B)
determine water-level adjustment 3.5
......................
s
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) ........r....................„.....„......
..,...;...,...............,.,,.......
1,
Figure 13.--Reproducible computation form.
15
COMMONWEALTH OF MASSACHUSETTS
t EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a DEPARTMENT OF ENVIRONMENTAL PROTECTION
A
/fib
TITLE Ala o� /1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMIENT9'',;�V,��
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:
Owner's Name: _
Owner's Address:
Date of Inspection:
Name of Inspector: please print) i`lL �'✓ /` �0 /
Company Name. l �4•
Mailing Address: •�• r 4
Telephone Number: �SDk• �� m
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.I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
Passes
Conditionally Passes .
Needs Further Evaluation by the Local.Approving Authority
ails
Inspector's Signature: �7 Date: l b U y
The system inspector shall submit a copy o 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
****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 page 1
Page 2 of l 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
a
Property Address:
Owner:
Date of Inspection:
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:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and over 20 years.old* or the septic tank(whether metal.or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate.of Compliance
indicating that the tank is less than 20 years old 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(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with
approval.of Board of Health):
broken pipe(s)are replaced-
obstruction is removed
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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION:(continued)
Property Address:
14
Owner /
Date of Inspection: ^i/ Aa 727
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
su_rface water supply or tributary to a surface water.supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system.has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic.tank and SAS and the SAS is less than 100 feet but 50.feet or more from a
private water supply well**. Method used to determine distance
**This.system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria 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.
3. Other:
I
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
< A14 A
Owner:
Date of Inspection: o
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the following for all inspections:
Ye 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''/z.day flow
7 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform 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.]
(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 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 systems in addition to the criteria above)
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 l;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.
4
Page 5 of l l
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGEDISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: f C ✓
IL�A
Owner:
Date of Inspection: �U4
Check if the following have been done.You must indicate.`yes"or"no"as to each of the following:
Yes No
Z _ 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)
V _ Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out?
V _ Were all system components,excluding the SAS,located on site?
_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the.Soil Absorption System (SAS)on the site has been determined based on:
Yes no j
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 SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 9 a_27�v
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 0..90
Number of current residents:
Does residence have a garbage grinder(yes or no)/}/
Is laundry on a separate sewage system(yes or no)yj:L& [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): QL6"
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy:�t/�C 1AA— 4aV/Z���Z641 ems- P
COMMERCIAL/INDUSTRIAI/� v
Type of establishment:
Design flow based on( 310 CMR 15,203 : d
g ) �v
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes 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 part of th inspection(yes or no):
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
�eptic 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)
—Tight tank —Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):
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: llo9 -04dQ-;2 1&44
Owner: �.e?� �-
Date of Inspection: i �, DU
BUILDING SEWER(locate on site plan) 1�Ch-
.
Depth below grade:
Materials of construction:_cast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc:): r.X
SEPTIC TANK: I/(locate on site plan)
Depth below grade:
Material of construction: P46oncrete_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: P.S`k
Sludge depth: V// u 1�
Distance from top of sludge to bottom of outlet tee or baffle:
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:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
As related to outlet invert,evidence of.leakage,etc.):
GREASE TRAP/bUo-cate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):.
7
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: / ajtZ4
DSO/
Owner:
Date of Inspection: O
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/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: �f 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.)*
P
PUMP CHAMBER/'(locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): .
1
8
Page 9 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
' A
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): /O (locate on site plan,excavation not required)
If SAS not located explain why:
Type
aching pits,number: 1 -
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,
tc): 0
CESSPOOLS: cesspool must be pumped as part of inspection)(locate on.site plan)
Number an 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 or 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.):
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:
v
Owner:
Date of Inspection: t
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 a ters the building.
I
1
3d
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: _
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water 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)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
® / 0 ZI Gl n S
11
rp/ 1
LO A I N SEWAGE PERT N0.
/ G
VILLAGE .
INSTALL R'S NAME i A DR SS q
BUIlDER OR OWNS
DATE PERMIT I SUED 67
DATE COMPLIANCE ISSUED
,.
n
��' 1 `�"`
� � � �.
C � �'�f
c'° o ��
�1 � �_
c�. � � —1
���-._� I
� � ,I
m
At
No..... .......... FEB..... :J...........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® PF HEALTH
�i✓ OF....................... " .....
Appliration for Disposal Works Tnnstrnrtiun rnmit
Application is hereby made for a Permit to Construct ()t-) or Repair ( ) an Individual Sewage Disposal
System at:
-------------- - ------------------------------•---- . .... ...... ...........................
L a io -A eg t No
Ow er Address
a F..... .._...:!! ............................................ ..................................................... ...........................................
Installer Addre s
Type of Building Size Lot......l.0f._ _ _-?----Sq. feet
U g— Expansion Attic ( ) Garbage Grinder ( )Dwelling No. of Bedrooms _a-................. ..........
Other—T e of Building ._.....
a -
Other—Type g __ No. of persons._.___.` ________________ Showers �( ) — Cafeteria ( )
P4 Other fixtures -------•----------------------------•-----------------
W Design Flow... _ .................................gallons per person per day. Total daily flow.........._.?.... G......gallons.
WSeptic Tank—Liquid capacity.IC P..gallons Length..... Width._l..h.......... Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....... !;2.1----sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed ............. Date..._
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..ti "_`�.�.._ .
f Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
•--•--.. .....
s------ -- .-- -•� �Q -•---•--'
O Description of Soil- --•---....---• --•----------------------
V ..............................................•-----•---•••-------•------------••-..................----......-•------•--••------••------•-_.....
-----------------------------------•-•-•----------------•------------------------------•-•---•---•-----•-----------...............-------•---------....-----•---...........................--•--------•.
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------------------------•-•-•----------•------•••-•••----------•------•••-------------•---•----•---------•------••---••-------....----------------------..........--•-••.......................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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 e oard of health.
Si ned- • -•............... . ---------------------------------------------- 0�3..1 ----
-•-•-
g !
® � Date
Application Approved By...�.%4._.._.......-•---------------•--•---...........---...-•----••---....--•-•---...... --•---.--------
----------------------
Date
Application Disapproved for the following reasons-------------•-•------------••----•---•-•---------------•----••--•-------------------------------..........------
.................•-------------•----------•----•------•-••-•-.....__...•-••---•-•--------....------•----•..
Date
Permit No.....� Issued.._=......� ,y /�
.....---•............. Date ..... .../ ....----------
No......Il _....... Fizz......C�.� ... ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�u/i✓........................OF......&�.......... /�
,�.ppliration fur Disposal Works Tontrairtion Prrutit
Application is hereby made for:.a Permit to Construct (Y- ) or Repair ( ) an Individual Sewage Disposal
System at: /t //�
. �...........�....f...:.a�r.I r ..:,. ....�:G► ......------•... .'••- ..-! .--- •-•-•-. .....................................
Lo atio-.-Address or /t o i N
......................_......................................................................... _� ....._.......... .. ......I............................
Address
i �t � ----•------ -------------------•--••-------
Installer Address
Type of Building Size Lot.......L L._L G 0 Sq. feet
Dwelling—No. of Bedrooms..... ......`•'.. ....................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building �>
a yp g ..�_._.._..�_.'.�_.r.�:'..._ No. of persons_._.__..`:�:•_�.............. Showers (� ) — Cafeteria ( )
dOther fixtures .----••------------------------•---.....------------........------------........---•---------•----...-•--------------...---•-----.........--•••.-•----
W Design Flow........`.-..................................gallons per person per day. Total daily flow......._..._ =- ?..._c9a.G.....gallons.
WSeptic Tank—Liquid ca.pacity..!!n.gallons Length._...'`_...... Width...r.(!_._..... Diameter................ Depth................
xDisposal 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 ( )
a Percolation Test Results Performed by. ! -%yam>................................................. Date....Z''�!l.%1. .__..
sir •�
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_.__.........__.._...__.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fYi ...........• ................... ........ ...............
•---------------
----------
D Description of Soil. C �t� �.......�" �.. �
x
W
UNature of Repairs or Alterations—Answer when applicable......................................................................................V.......
-----•-•-•-•----------------•-------------------.....---•--•---•-........------------..............------•----••----------------------•----•---------------------•----•---------•--•--------••••-••----•
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 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.
Si ned,.. -�-'�'-•---•---•---`---' c .....
"=
g .......• ........
f Date
Application Approved By-•-•-�14-------------------------•--•-•--•---•-----.................----................
Date
Application Disapproved for the following reasons-------------------------•---------•------------------------••------------------•-----------------............
.................................................................•-------..--.........._.......•-•--.---
��,,// Date
Permit No....--� ------------•--•--------------------•--- Issued---. :------
Date
HE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
:.......................OF.... r...........................................
furdifirtttr of Toanplianrr
THIS IS TO CERTIFY, T t the Individual Sewage Disposal System constructed (X ) or Repaired ( )
bye �.�:.1 ...................................... ................................
at....... .p.?..._.. k,_ _..�� lS'�7. .Installer e�;
of The
has been installed in accordan�with the provisions of TITLd r5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No--- ....................... dated-------- ".4+ _rf'^. Jr...................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS '
BOARD OF HEALT
��✓...................... ........................................
`'
No..........�1 ..:... FEE...r�...:�............
;Disposal Vorko oaf it ion rrattit
__
Permission is hereby granted. ;-,,1�.�a!---�=----'�--••-•-�-----•-------•----•-•-----------------------------•---......-•---•---•--•-•--...._.
to Construct ( or Repair ( ) Individual ewage Dis osal System
ye
/ X Street
as shown on the application for Disposal Works Construction Permit No........1i.7...... Dated......±._l'a'��`..��.........
„ y
. t•DATE................................................................................. Board of Health
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
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SECTION A -A i4afhe 1 1111 f 1 1�
ALL OUTLET PIPFS FROM THE
10' min. from *NOTF: ALL PIPES ARE TO BE 4" SCHEDULE 40 P-V C VENT PIPE (0 Least 24 inches tail) PROFILE VIEW OF ADDITION TO LEACHING SYSTEM DISTRIBUTION BOX SHALL BE 12' CONCRETE COVER
cm:tank Schedule 40 PVC w/Chorcoal \1 SET LEVEL FOR AT LEAST 2 FT.
Existing Foundation house to septic Odor Filter
3* of 1/8' - 1/2" Washed Peastone---\
TOP OF FOUNDATION ELEV. 100.00 (Assumed) Septic tank covers must be
Stone- 3 - 5'OUTLET 77*,�--?--!�:.'_
within 6 in, of finished grade v-3/4" to 1 1/2 Washed Crushed
Door SAS 99.00 KNOCKOUTS
-Grade over D-Box 99�00
Septic Tank 99,00
z 12- INLET
OUTLET , I ?
or;
S 02 3 HOLE H--10 �-Top Load El- =95.75 .1 61
DIST BOX IF
-01 or Greater _44 Or I
EXIST. _vj
4 1.75*
3' Maximum Cover
IZ Z
1.000 GAL. S- 0.01' per foot SCH, 40 Tee- 10
NEW PIPIF 0 10 Effective Depth X in
FR[N4 EXIST. FOUNDATION SEPTIC TANK C1`1
0 20 5 Units 6.25' 30' fA
H-10 t6 *00 .....
0
0-aw" 3 3
Eg OF 20 0
> U1 0.83' (10 inches)
CONCRETE FULL FO~ 0 if (6 31 25�--
>
0 to 3 HOLE H-10 DISTRIBUTION BOX
6 in of 3/4'-1 112 >
SYSTEM PROFILE compacted stone > > rn Effective Length NOT TO SCALE F__
Not to Scale C 4' SOIL ABSORPTION SYSTEM (SAS)
c
>
INFILTATROR HIGH CAPACITY (H-eJO LOADING)/ GEORGE O'BRIEN GENERAL NOTES
6 in.of 3/4 -1 112'
compacted stone Effective Vidth (OR EQUIVALENT) Not to Scale 1 Contractor is responsible for Digsafe notification
0
�_RISERS TO WITHIN�6- BELOW GRADE M and protection of all underground utilities and pipes.
NOTE: ALL COMPONENTS MUST HAVE Bottom of Test Hole 1 Cle-88.00 NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18" /EFFECTIVE HEIGHT IS 100
No Groundwater Observed 0 132*
2. The septic tank and distribution box shall be set
level on 6" of 3/4"--1 1/2" stone.
3. Backfill should be clean sand or gravel with no
stones over 3" in size.
4. This system is subject to inspection during installation
by Carmen E. Shay - Environmental Services, Inc.
5. The contractor shall install this system in accordance
with Title V of the Massachusetts state code, the approved plan
PERCOLATION TEST and Local Regulations.
N 13d 02' 59" E 6 If, during installation the contractor encounters any
Date of Percolation Test: APRIL 30, 2004 soil conditions or site conditions that are different
Test Performed By. CARMEN E. SHAY, R.S., C.S.E. from those shown on the soil log or in our design
Results Witnessed By. WAIVER ( per Barnstable B.O.H.) 75.03' installation must halt & immediate notification be
SHAY ENVIRONMENTAL SERVICES, INC. made to Carmen E. Shay - Environmental Services, Inc.
Percolation Rate: Less Than 2 MPI @ 48" 7. No vehicle or heavy machinery shall drive over the
septic system unless noted as H-20 septic components.
8. Install Tuf--Tite gas baffles or equals on all outlet tee ends.
9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
-1 10. All solid piping, tees & fittings shall be 4" diameter
Test Hole Schedule 40 NSF PVC pipes with water tight joints.
DEPTH No_1 - 11. Municipal Water is Connected to ALL OF The Residence and Abutting
SOILS ELEV.
0 99.00 Properties Within 150 Feet.
Sandy
ko THE PROPERTY LINES ARE APPROXIMATE AND
Loom
COMPILED FROM THE SURVEY PLAN GENERATED BY
10 Y 3/2 � NORMAN GROSSMAN, C.E., OF HYANNIS, MA
0'-10" A. 9a.t2 Failed to ENTITLED " SUBDIVISION PLAN OF LAND IN BARNSTABLE,
Sandy Leach PIt ko MA", DATED MARCH 16, 1973, PLAN BOOK 273, PAGE 94
Loom LOT #37A to AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
10 YR 5/6 t--12.25'- -37.25' -25.75 to'- -46" LOT #35A IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
Bw 95.10 THE SEPTIC SYSTEM INSTALLATION.
cn
-Med 4" PVC
Sand to EXISTING LEACH PIT TO BE PUMPED OUT AND
PROJECT BENCH MARK VENT L
2.5 Y 7/4 REMOVED 10 FACILITATE NEW SEPTIC SYSTEM INSTALLATION
46"-132' C, 88.00 TOP OF FOUNDATION
ELEV. = 100.00 (Assumed) D-Box TEST HOLE #1 NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
0 ELEV.= 99.00 FROM THE EXISTING LEACH PIT TO BE DISPOSED
20.5, EXIST. 1000 gal. OF AS PER BOARD OF HEALTH SPECIFICATIONS.
Septic Tank NO WETLANDS ARE PRESENT WITHIN 200- OF THE PROPERTY
ASSESSORS MAP 310, PARCEL 422
DECK
LEGEND
Perc #1 EXISTING DENOTES PROPOSED
Depth to Perc: 48" to 66" 2 BEDROOM 104XII SPOT GRADE
Perc Rate= Less Tha 2 MPI
Groundwater Not Observed 11011SE DENOTES EXISTING
No Observed ESHWT #169 X 104.46 SPOT GRADE
ADJUSTED H2O Elev. None E
Cc
_Z__ I C\1
PL
PROPERTY LINE
PROPOSED CONTOUR
LOT #36A I r-
10,888 Square Feet 98 -97 EXISTING CONTOUR
o ---1 ASPHALT DEEP TEST HOLE &
TYPICAL 1000 GALLON SEPTIC TANK
NOT TO SCALE ------75.00' DRIVEWAY
PERCOLATION TEST LOCATION
2-18' DIAM. ACCESS MANHOLES A, IN 14d ' 4' 05" E 6 FOOT STOCKADE FENCE
A
U 0 MJ::>A S7
PLOT PLAN
INLET
AFT (40 FOOT RIGHT OF WAY)
OF PROPOSED SEPTIC SYSTEM UPGRADE
THE ACCESS COVERS FOR THE SEPTIC TANK,
DtSTRWT10N BOX AND LEACHING COMPONENT PREPARED FOR
SET DEEPER THAN 6 INCHES BELOW FINISHED
GRADE SHALL BE RAISED TO *THfN 6' OF
STEEL'REINFORCED PRECAST CONCRETE FINISHED GRADE' JOHN W. DENT
PLAN VIEW INSTALL TUF-TITE GAS BAFFLES OR EQUALS AT
3-24' KMOV i ABU COVERS A # 1 6 9 COMPASS CIRCLE
4�' CENTERVILLE , MA
1 3' min. Clearance I
XT_T__J2'_nntn. ".t to outlet
INLET min
I ---
OUTLET TLE T Design Calculations
T Lk id level PREPARED BY:
Li OF
5' 7- 5' 7'
Number of Bedrooms 2 Equivalent to 220 Col./Day (330 Gal./Day Min. per Title V)
Eg 4'-0' nni. 1- Garbage Grinder: No R, CARNEY E. SAJA Y
-0 Liquid depth 6.0% Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V)
0
Septic Tank 2 x 330 Gol./Day = 660 USE EXIST. 1,000 GAL. Septic Tank. 0 20 40 50 0
H NVIRONMENTAL SERVICES, INC.
SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch
Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. P.O.
273.8 gallons No. BOX 627
4' -to'�-- Sidewall Area: 0.74 got./sq. ft. x 78 sq. ft. = 58 gallons ISTIE EAST FALMOUTH, MA 02536
CROSS SECTION END-SECTION Providing: 331.80 gallons SCALE: 1 "=20' IT IR\ TEL/FAX : 508-548-0796
Use: (5) INFILTRATOR HIGH CAPACITY H-10 UNITS, HAVING A 0.83' 00 INCHES) EFFECTIVE DEPTH, SCALE: 1 '=20' DRAWN BY: CES DATE: MAY 7, 2004
TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE
ON THE ENDS. NO STONE UNDER. PROJECT#SD570 FILENAME: SD570PP.DWG SHEET 1 OF