HomeMy WebLinkAbout0006 CROSS WAY - Health 6 CROSS WAY, HYANNISPORT
A= 245 104
a
I
r
e
A
u e
I t
Commonwealth of Massachusetts a J15,
,p Title 5 Official Inspection Form
13 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l; _
6 Cross Way-System 1 of 2 Assessor's Map: 245 Parcel: 104 `
Property Address h
James and Ellen Herrington
Owner Owner's Name
information is �'
required for every Hyannis t/ MA 02601 October 16, 2018 C
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 filling out forms A. Inspector Information Sf on the computer,
use only the tab David D. Coughanowr, R.S.
key to move your Name of Inspector
cursor-do not Eco-Tech Rapid Response
use the return Company Name
key.
155 George Ryder Road South
r� Company Address
Chatham MA 02633
City/Town State Zip Code
»n 508 364-0894 1328
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
,SN OF MqS
4. ❑ Fails
DAUID You,
OU HA OWR N
October 16, 2018
Inspector's Sig tur p Date
FC,/Sl_EY,
The system in I�.aik it a copy of this inspection report to the Approving Authority (Board
of Health or DEP) M—hsa1C, 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 1 of 2 Assessor's Map: 245 Parcel: 104
u
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
Inspector's Notes==> The septic system described herein is deemed to pass this Real Estate
Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-
5, or specified by local regulations. The scope of this inspection is limited to health and environmental
compliance and the septic system has been evaluated according to the conditions observed on the
day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination.
Removal of garbage grinder is recommended
2) 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):
t5insp.doc-rev;7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
it
- 4 � •.c
c Commonwealth of Massachusetts
+ry Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 1 of 2 Assessor's Map: 245 Parcel: 104
v
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u-
6 Cross Way- System 1 of 2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
,e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 1 of 2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 'h 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.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® 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.
5) 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 CA.
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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 1 of 2 Assessor's Map: 245 Parcel: 104
V�
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. CityFrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no" for each of the following for all inspections:
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)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
m
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 1 of 2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a-no plan
Description:
Two separate systems exist on this property. This one handles 3 bedrooms and the other serves the
4th bedroom (separate report).
Number of current residents: 2
Does residence have a garbage grinder? ® Yes ❑ No
Does residence have a water treatment unit? ® Yes ❑ No
If yes, discharges to: Filtration system - no discharge
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)): 29 gpd
Detail:
2017: 7481 gallons 2016:13746 gallons
Sump pump? ❑ Yes ❑ No
Last date of occupancy: current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 1 of 2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v—
6 Cross Way-System 1 of 2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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:
26+ years. Certificate of Compliance for a new system was issued 3/6/1992 (Permit#92-63 at Health
Department).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 2
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.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
c Commonwealth of Massachusetts
r p, Title 5 Official Inspection Form
_ I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l;
6 Cross Way- System 1 of 2 Assessor's Map: 245 Parcel: 104
u
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 0.5
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: 8.5 ft x 6 ft x 6 ft- 1000 gallons
Sludge depth: 4 inches
Distance from top of sludge to bottom of outlet tee or baffle Winches
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle 10 inches
Distance from bottom of scum to bottom of outlet tee or baffle
14 inches
How were dimensions determined? permit application
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time. Maintenance pumping is recommended within 2 years and every
2-4 years thereafter with year round occupation. Tank and tees appear structurally sound and
functioning as intended. No evidence of leakage in or out was observed.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
6 Cross Way- System 1 of 2 Assessor's Map: 245 Parcel: 104
v
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
.. Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
i;
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 1 of 2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert at outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
No adverse conditions observed.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection , Form
�= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I Sus e
9 p Y Y
6 Cross Way- System 1 of 2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. 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:
1
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
< � 6 Cross Way- System 1 of 2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was
observed. A hole was dug into leaching gallery stone and no effluent or effluent contact staining was
observed in the stone or overlying soils.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Cross Way-System 1 of 2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every H annis MA 02601 October 16, 2018
y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
P P 9 P Y 9
Commonwealth of Massachusetts
,.p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
6 Cross Way- System 1 of 2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every H annis MA 02601 October 16, 2018
y
page. rityrrown State—Zip-Code—Date-of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
SEPTIC INFO A, (LOCATIONS
®o—E C H;U -OF SEPTIC COMPONENTS
I -DISTANCES IN DECIMAL FEET
A 8 C D
1 23.5 1 --- ---
2 29 12
3 31.5 26
- - - - — - 4 --- --- 21 _ 9
5 --- --- 23.5 13.5
b --- --- 24 28
LEACHING GALLERY DRIVEWAY
DISTRIBUTION BOX i31
1
SEPTIC TAW
GALLON ► 2
A THIS SKETCH IS
B BEST VIEWED IN
COLOR FORMAT
LEACHING
C GALLERY
EXISTING F6
DWELLING
4F�:A 5 b o�T
D 100E
GALLON
SEPTIC
y TANK
NOT �u
TO o ..
SCALE rn �G�1C
508 364-0894
CRESS WAY
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
'R r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
` 6 Cross Way-System 1 of 2 Assessor's Map: 245 Parcel: 104
v
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. CityFrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 4 ft+
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:
Previous inspection report
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Previous inspection report indicates 4 feet to high groundwater. A hand augured test boring showed
no groundwater 2 feet below SAS.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
cam, Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 1 of 2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
�s - i0 y �_
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�C 6 Cross Way-System 2/2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
a.'
information is
required for every Hyannis V/ MA 02601 October 16, 2018 Sr.
page. City/Town State Zip Code Date of Inspection
Batt
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. Inspector Information 674 33 93
filling out forms
on the computer,
use only the tab David D. Coughanowr, R.S.
key to move your Name of Inspector
cursor-do not Eco-Tech Rapid Response
use the return Company Name
key.
155 George Ryder Road South
rQ Company Address
Chatham MA 02633
Cityrrown State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further tion by the Local Approving Authority
1, jN OF A4,q
4. El Fails �o� DAVID YG�
D
COU AN WR � R-5 October 16, 2018
Inspector's Si to ��STE��c Date
The system in sF4qq / ubmit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) wit in 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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: 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. y 7 fF-TCSriQ 4v 6i �7 1r=i
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pag`e i`W18
Commonwealth of Massachusetts
m Title 5 Official Inspection Form
(r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v-
6 Cross Way- System 2/2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) 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:
Inspector's Notes==> The septic system described.herein is deemed to pass this Real Estate
Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-
5, or specified by local regulations. The scope of this inspection is limited to health and environmental
compliance and the septic system has been evaluated according to the conditions observed on the
day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination.
Removal of garbage grinder is recommended
2) 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. ar
Y -
*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):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
t Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way-System 2/2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) 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.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 2/2 Assessor's Map: 245 Parcel: 104
v-
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
c Commonwealth of Massachusetts
- Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 2/2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. CityTTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 'h 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.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
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 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) 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 CA.
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 11 of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
i ,p Title 5 Official Inspection Form
i,
�1; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 2/2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
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)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Cross Way-System 2/2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): n/a Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a- no plan
Description:
Two separate systems exist on this property. This one handles 1 bedroom and the other serves the
other 3 bedrooms (separate report).
Number of current residents: 2
Does residence have a garbage grinder? ® Yes ❑ No
Does residence have a water treatment unit? ® Yes ❑ No
If yes, discharges to: Filtration system - no discharge
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ®'No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)): 29 gpd
Detail:
2017: 7481 gallons 2016: 13746 gallons
Sump pump? ® Yes ❑ No
Last date of occupancy: current
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v-
6 Cross Way- System 2/2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
c Commonwealth of Massachusetts
A Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Yn
� 6 Cross Way- System 2/2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. 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):
Septic Tank and Leaching Gallery
Approximate age of all components, date installed (if known) and source of information:
Not determined -(No information on file at Health Department).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 1.5
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.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
l;
6 Cross Way- System 2/2 Assessor's Map: 245 Parcel: 104
u� Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 0.25
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: 8.5 ft x 6 ft x 6 ft- 1000 gallons
Sludge depth: 2 inches
Distance from top of sludge to bottom of outlet tee or baffle 32 inches
Scum thickness trace
Distance from top of scum to top of outlet tee or baffle
10 inches
Distance from bottom of scum to bottom of outlet tee or baffle 14 inches
How were dimensions determined? probe
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping not required at this time. Maintenance pumping is recommended within 2 years and every
2-4 years thereafter with year round occupation. Tank and tees appear structurally sound and
functioning as intended. No evidence of leakage in or out was observed.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 2/2 Assessor's Map: 245 Parcel: 104
�.,
Property Address
James and Ellen Herrington
Owner Owner's Name
information is Hyannis MA 02601 October 16, 2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
li i,
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 2/2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
115Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`...........e �� 6 Cross Way- System 2/2 Assessor's Map: 245 Parcel: 104
�.,
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. 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:
1
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
c � Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 2/2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is requi-ed for every Hyannis MA 02601 October 16, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
1.1. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was
observed. A hole was dug into leaching gallery stone and no standing effluent or effluent contact
staining was observed in the stone or overlying soils.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
cam, Commonwealth of Massachusetts
i Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way-System 2/2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
i ,�,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�� / 6 Cross Way- System 2/2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. Cityllown State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
����1� I�FO �� LOCATIONS
®o -OF SEPTIC COMPONENTS
-DISTANCES IN DECIMAL FEET
A 8 C D
1 23.5 1 --- ---
2 29 12
3 31.5 26
4 .-.-- ---. 21 9
5 --- --- 23.5 13.5
b --- --- 24 28
LEACHING GALLERY DRIVEWAY
DISTRIBUTION BOX !3�
100E GALLON 1 2
SEPTIC TANK
A THIS SKETCH IS
B BEST VIEWED IN
COLOR FORMAT
LEACHING
C GALLERY RU
EXIS TiNG
DWELLING
4F7:A 5L .- -I!
b owl rn
D 1000 u n
GALLON
SEPTIC
y TANK
NOT n Lv
TO
/ ..
a
SCALE
508 364-0894
CROSS WAY
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
= I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. � 6 Cross Way- System 2/2 Assessor's Map: 245 Parcel: 104
v
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
I
Estimated depth to high ground water: 4 ft+
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:
Previous inspection report
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Previous inspection report indicates 4 feet to high groundwater. A hand augured test boring showed
no groundwater 2 feet below SAS.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
c Commonwealth of Massachusetts
r Title 5 Official Inspection Form
r Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
6 Cross Way- System 2/2 Assessor's Map: 245 Parcel: 104
Property Address
James and Ellen Herrington
Owner Owner's Name
information is required for every Hyannis MA 02601 October 16, 2018
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in'this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
v
a-
p
r
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld Trudy Cox*
Oovem„ 'eft
Argeo Paul Cellucci David B.Struhs
LL Gammor // /O Commmlorw
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
ry\: CERTIFICATION
Property Address: C�CD Address of Owner) qy •/`j�� `�.
Date of Inapectiori (If different) to .
Name of Inspector.
Company Name,AddressandTelephone Number. ��TtioFTsq� 1`9,9�
3to .
CERTI�FICATI STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information ceported beo is.truQ',=accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_v Passes
Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails ,
Inspector's Signature: f/ �� Date:
r
The System Inspector s mit a copy of this: report to the Approving Authority within thirty(30)days of completing this
inspection. If the system of 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A,B,C,or D: ,
A) SYSTEM PASSES: /
�Iha"not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
inspection.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal, cracked,structurally unsound,shows substantial infiltration or exf'iltration,-or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank as approved
by the Board of Health.
(revised 11/03/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(617)SW1049 a Telephone(617)292-ON
�A1 Pnnted on Recycled Paper
it
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) ;
Property Addreaa:
Owner.
Date of Inspection:
Bl SYSTEM CONDITIONALLY PASSES (continued) .
�ry
_ Sewage backup or breakout or high static water level observed in the distribu 'on box is due to broken or obstructed pipe(s)
or due to a broken,settled or uneven distribution box. The system will pass i pection if(with approval of the Board of
Health):
broken pipe(*)aZPlaced
d _obstruction is reribution bah: or replacedThe system required pumping more than fourear du to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Bos, 00f H TMbroken pipe(s•)adobstruction is C1 FURTHER EVALUATION IS REQUIRED BY THE O- HEALTH:
Conditions exist which requu�e further evaluation by the OF
Health in order to determine if the system is failing to protect the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD/OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT7E PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT.
_ Cesspool or privy is within "'0 feet of a surface water i
P� P `'Y .�
_ Cesspool or privy is wit 50 feet of a bordering vegetated wetland
or a_salt marsh.
Z) SYSTEM WILL FAIL UNLES THE BOARD OF HEALTH (AND PUBLIC�WATER SUPPLIER,IF APPROPRIATE)
DETERMINES THAT THE YSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVI ONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
_ The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis 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 equal to or less than 5 ppm.
3) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address
Owne
r.
Date of Inspection:
D) SYSTEM FAILS: r
I have determined that the system violates one or more of the following failure criteria defined in 310 CMRt15.30V The basis for
this determination is ident' below. .The Board of Health should be contacted to Bete what will be necessary to correct the
failure. _
Backup of sewage into facility or system component due to as 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 distri ution box above outlet invert</to overloaded or clogged SAS or cesspool.
_ Liquid depth in cesspool is less than 6"below invert or available volume is leas than 1/2 day flow.
Required um more than 4 tunes m the last NOT due to clogged or obstructed i (s). 4
_ �9 pumping yam'_ � P�Pe
Number of times pumped
Any portion of the Soil Absorption
nSSystein, cesspool or privy is below the high groundwater elevation.
_ Any portion of a cesspool or privy is within\100 feet of a surface water supply or tributary to a surface water supply.
_ Any portion of a cesspool oT privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50\t of a private water supply well.
Any portion o ja 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. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coldorm cteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LARGE SY3 FAILS:
The following criteria apply to large systems in addition to the criter above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: �oclev'ti
Owner. � ..
Date of Ins ion: -
Check if the following have been done:
L-Pumping information was requested of the owner,occupant, and Board of Health.
one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
during pe ,
As built plans have been obtained and examined. Note if they are not available with N/A.
C-11-e facility or dwelling was inspected for signs of sewage back=up. -
'The system does not receive non-sanitary.or industrial waste flow
vThe site was inspected for signs of breakout.
vAll system components,excluding the Soil Absorption System,have been located on the site.
The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles.or
toes,material of construction,dimensions, depth of liquid,depth of sludge,depth of scum.
'L The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
C_/The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95)
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner.
Date of Inspection. 4 *.
FLOW CONDITIONS
RESIDENTIAL
Design flow: `�O one
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no): `
Laundry connected to system(yes or no):
Seasonal use(.yes or
Water Wter readings, if adailable:
Last date of oocupancy:-S� F
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow:_____pnllons/day
Grease trap present: (yes or no)_ w
Industrial Waste Fidigg Tank present: (yes or no)_
Non-sanitary waste discbZW— =to the Title 5 system: (yes or not
Water meter readings,if available'.
Last date of occupancy:
OTHER be)
to of occupancy:
GENERAL INFORMATION '
PUMPING RECORDS and source of information: ' - -
G'12.L—
System Pumped as part of inspection: (yes or not
It
pumped: O
yea,volume ped: ,i U0 ons
Reason for pumping: /�c�;.Ylir tl.�4tr p
TYPE OF TEM
Septic tan)</distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all.components,date installed(if known)and source of information: 9/ J ✓C
Sewage odors detected when arriving at the site:(yea or no) AU
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C,
SYSTEM INFORMATION (continued)
i .�., .
�
Property Address: '
Owner.
Date of Inspec on:
2— �L-4' w
SEPTIC TANK:_
on site
(locate Plan
Depth below grade: y
Material of construction: concrete_metal_FRP._other(e:plain) �---
d
Dimensions: s`
Sludge depth: --
outlet tee or baffle: a
to bottom
of ou �—
Distance from to sludge
P of
Scum thickness:
Distance <<
from top of scum to top of outlet tee or baffler Gy
Distance from bottom of scum to bottom of outlet tee or baffle:_
Comments:
(recommendation for pumping,condition of' et and outlet tees.or baffles,depth of liquid level in tion to outlet ' rt,structural integrity,
eviden of leakage, etc.)
ez
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _oencrete_ tal_FRP other(explain)
Dimensions:
Scum thicimess:
Distance from top of scum to top of out tee or baffle: ;
Distance from bottom of scum to m of outlet tee or baffle:
Comments:
(recommendation for ping,condition of islet and out
tees or baffles,dept f liquid level in relation to outlet invert,structural integrity,
evidence of leakage, etc.)
6
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) ,
Property Address
Owner.
Date of Inspection:
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: concrete_ FRP other(explain)
Dimensions:
Capacity: nuona
Design flow: gallons/day r
Alarm level: y
Comments:
(condition of' tee,condition of alarm and float switches,etc.)
i
DISTRIBUTION BOX: e
(locate on site plan)
Depth of liquid level above outlet invert: Q r
Comments:
(note if level and distribution' equal, evidence of solids r,evid ce of le0ageinto or out of box,etc.) 6
PUMP CHAMBER_ _.
(locate on site plan)
Pumps in working orden(yes or no) ,
Comments:
(note omuhtion of pump chamber,condition of pumps and, �nanees,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM f
PART C
SYSTEM INFORMATION (continued)
Property Address
Owner. ��nn
I ' '
-41
Date of Inspect on: U
E••.,
SOIL ABSORPTION SYSTEM (SAS):L--- 4
ted non-intrusive methods)
t be approximated but may excavation no
t aired by
site if possible; required, y PP
(locate on plan,
P
If not determined to be present,explain:
•
Type
leaching pits, number: -
leaching chambers, number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields, number; dimensions:
overflow cesspool,number:
Commen : (ngp condition of soil,.signa f by ulic failure,level of ponding, ndition of vegetation,etc.)
47
1124
CESSPOOLS:
(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(cesspool must be pumped as part of inspection)
6
Comments: (note condition of soil, signs of hydraulic level of ponding ndition of vegetation,etc.)
PRIVY:_
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids: .
Comments:(note condition o soil,signs of hydraulic failure,level,of ponding,condition of vegetation,etc.)
(revised 11/03/95)
8
b.z
SUBSURFACE'SEWAGE DISPOSAL SYSTEM`INSP.ECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Addre s: 6 rya
Owner:
Date of Inspecti
SKETCH OF SEWAGE DISPOSAL SYSTEM:"
include ties to at least two permanent-references landmarks or benchmarks
locate all wells Nithin 100'
44-1
33
F
s
A -�-
D-3
DEPTH TO GROUNDWATER
Depth to groundwater:;- feet
method of ete inatiOrt or oximation: O'�
(revised •/15/9s) 9
No....�10....6 3 Fss... x:2....-..
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Applira#ion for Bi-ghoul Works Tnnidrnrtinn ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
... -....F^c ...2. ./I- ._ ................... .......•-----•--................----------- ---•------•-....................._.......--
!v J Location-Addr ............................................77 or Lot No.
WTf er Address
Installer Address
Q Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bed rooms___..._.....................................Expansion Attic ( ) Garbage Grinder ( )
`q Other—T e of Building ��s t��/ 3
a —Type g .r.J....................11i �To. of persons................._......___. Showers ( /) — Cafeteria ( )
Other fixtures - -------------------•----------------------
........__..
W Design Flow...........................................gallons per person per day. Total daily flow--_-----.-........_._..........._...........gallons.
WSeptic Tank—Liquid capacity/�M.?__-gallons Length................ Width....o........ Diameter---------------- Depth................
x Disposal Trench—No......`1.......... Width............... Total Length......J�........... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( r ) Dosing tank ( )
1-4 Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fit Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................
ODescription of Soil............5� ' -------------------------------------------------------------------------------------------- --------------..----......
U ---------•-----------------------------------------------------------------------•----------------------------------------------------•---------------------------------------------•-----....._-•----
W ----------------------------------------------------------------------------------------------------------------- - ------
-- - --- --- - ----- --
U Nature of Repairs or Alterations—Answer when applicable.._____ 2 f Y 5
up - ------------------------------------------------------- ....----
- ---------------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the �I
system in operation until a Certificate of Compliance hVIFen issued by the board of health.
Signed .................. ......... ......�--....------- .-------�--........
------2- --//� �2.
Date
-------------
Application Approved BY �'^ ^. ',�..... ........................... ... ------ ........
Date
Application Disapproved for the following reasons: ..---- --- -------------------------------------- -------- --------------------..........................................
---------------------------- ------------------------- -------- ------------------------------------------- ----------------------- ---- --- --................................................... ........................................
Permit No. ....-----7.'L-- 63...................... Issued .........................................................D ace- to
Date
No....9a....-.6:3 Fps... -_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for MipviiFal Warkii Tonotrnrtiott a mit
Application is hereby made for a Permit to Construct ( ) or Repair ( } an Individual Sewage Disposal
System at:
......................................... ............................................ ....-----....-----------......-----------
--- -------------
Lor
yt/ Lo/caattiron-Address�I or Lot No.
.. �J.Y.. .�L..'e..-........./.' ..../T'K 4............................. -••........................................ . .........................................
....
P Address
— caner
Installer Address
UType of Building Size Lot................ Sq. feet
t-, Dwelling—No. of Bedrooms..........�..................................Expansion Attic ( ) Garbage Grinder ( )
aa Other—T e of Buildiii ✓�F'4 /��Mn ,�T
—Type g ..........:....... . /1V 0. of persons.........��................. Showers ( �) — Cafeteria ( )
a4Other fixtures -----------------------•-•-•--•---•----•--•--•-••-•-----••----------...------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity>aGo--.gallons Length................ Width................ Diameter.---..---------- Depth................
x Disposal Trench—No......`7............. Width................ Total Length---...3.v...... 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. 1................minutes per inch Depth of Test Pit-----.........---... Depth to ground water........................
fZ4 Test Pit No. 2................minutes per inch Depth of Test Pit...---.............. Depth to ground water.......--...............
9 ----------- ------------------------------
•-------------
•--------------
Description of Soil............5'y........i...................
....
---•----------------------------------------------
•---------------------•----------------------••-------------------
x
W
Nature of Repairs or Alterations—Answer when a licable-------. _--A�.��..-----...�'4/ ,-e�.........�`^U P PP ---------------
'� /� f............:2--------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance havren issued by the board of health.
Signed ---------------------------- ----- ---1/-�.................................---..............----- ........................................
Date
Application Approved By --- ....... - --------�� .--
' a------------------------------------------------------------- �- t�
� - t Date,
Application Disapproved for the following reasons: -- ------------------ ---- ------- ----------------------------- - ----------------------------------------------------
.........-
-- --........ .............. .------.....--- --------...--------- .. . --------. ---..........-----... .----------.....---- ------..............................
PermitNo. ......... -- - .... ��-------------------------- Issued ...............................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
u�Prttftaratr of �LIIZapti n rE
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by10...:... 't -------------------------------------------------------------------------------------------------------------------------------------------------------------------
Installer
at ...........�-
has been installed inVccordance with the provisions of TITLE 5 of The State Environmental Code as described in
PP P .2..-.�. --------------....................
the application for Disposal Works Construction Permit No. ...... -------...: dated -------------.. .
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE........................
. ............... - 6 - ---,--------------------------------------------- Inspector ----...-----��--,----.�...---'----•-------.-................------............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No.... c2_'.�J?� . �' FEE._3'1�..)
R Osa Wo.�rks Cnono#r ion rrtttit
Permission is hereby granted-----------V --
------ --•-•--• .lh' :----------------------•----•---------------•---......------...................-•---•---
to Construct ( ) or Repair an Indivi ual Sewage Disposal System
at No........... ........
•--• - ....................... '
--.... .
St et n
as shown on the application for Disposal Works Construction Permit No. � G
-•--- Dated. ..................................................._
.
�DATE........... ..-.��._`.!_ 1........................................ Board of Health
s.
FORM 36508 HOBBS&WARREN.INC.,PUBLISHERS