HomeMy WebLinkAbout0080 DOLPHIN LANE - Health 80 Dolphin Lane
Hyannis
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Dolphin Lane
Property Address r .
Linda Delaney Ann Meaney,Robert Delaney Marjory Fraser,Catherine Resch
Owner Owner's Name/
information is ;I Ma 02601 10/15/2020
required for every Hyannis
State Zip Code Date of Inspection
page. City/Town
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 S #� �"
filling out forms
on the computer, Sean M.Jones
use only the tab
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
use the return Company Name
key. 74 Beldan Lane
VQ Company Address 02632
Centerville _Ma
State Zip Code
CityrTown
774-248-4850 smjonestitle5@gmail.com, S1 452ense Number
sean@sTjonesbtie5.com
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 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. 0 Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
10/15/2020
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection.If the system 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.
Tftle 5 official Inspection rorm:subsurface Sewage Disposal system•Page 1 of 18
t5tnsp.doc•rev..712612018 .
n
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney,Ann Meane ,Robert Delaney,Ma'o Fraser,Catherine Resch
Owner Owner's Name
information is Ma 02601 10/15/2020
required for every Hyannis — state Zip Code Date of Inspection
page. Cdyrrown
C. Inspection Summary
Inspection Summary:Complete 1,2,3,or 5 and all of 4 and 6.
1) 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:
The property located at 80 Dolphin Ln Hyannis is served by a Title V septic system consisting of a
1500 gallon septic tank,distribution box and 3 flodiffussers. Although the system was found to be in
proper working condition at the time of inspection this report does not guarantee future performance
under similar or increased usage.
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 ff a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
Title 5 ofWal Inspection Form:Subaurface See ge Disposal System•Page 2 of 18
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i
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney,Ann Meane , Robert Delaney, Madory Fraser,Catherine Resch
Owner Owner's Name
information is H Ma 02601 10/15/2020
required for every Hy�annis State Zip Code Date of Inspection �
page.
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):
❑ Y ❑ ND(Explain below):
obstruction is removed ❑ ❑ N
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:
Trda 5 Debi Inspection Form:subsurrace sewage Disposal System•Page 3 of 18
t51nsp.doc-ray.7rSWi8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney,Ann Means , Robert Delaney,Ma(jory Fraser,Catherine Resch
Owner Owner's Name
information s Hyannis Ma 02601 10/15/2020
requited for every Cit alms State Zip Code Date of Inspection
page.
rrown
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
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
Tile 5 Official b spection Form Subsudece Sewage Dispose!System-Page 4 of 18
t5inap,doc•rev.7@8Yl018
d\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney,Ann Meane , Robert Delaney,Ma dory Fraser,Catherine Resch
Owner Owners Name
information is Ma 02601 10/15/2020
Hyannis
H
required for every C /Town State Zip Code Date of Inspection
page.
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 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
El ❑ 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
Title 5 Official Inspection Fwm:Subsurface Sewage Disposal System•Page 5 of 1a
t5insp.doe•rev.7126=18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Dolphin Lane
Properly Address
Linda Delaney,Ann Meaney,Robert Delaney Marjory Fraser Catherine Resch _
Owner Owner's Name
information is Hyannis Ma 02601 10/15/2020
required for every H annis state Zip Code Date of Inspection
page.
rown
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 GA 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 16.304.The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the following foram 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)]
Sewage Ms sal System•Page 6 of 18
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Title 5 Official Inspection Form:S�&surrace evrag po
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney,Ann Meane ,Robert Delaney,Ma'o Fraser,Catherine Resch
Owner Owner's Name
information is Hyannis _ Ma 02601 10/15/2020
required for every crrown State Zip Code Date of Inspection
page.
D. System Information
1. Residential Flow Conditions:
3
Number of bedrooms(design): 3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
330 pad
Description:
F
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
if yes,discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings,if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
seasonalusage
Last date of occupancy: Date
Title 5 official Inspection Form:Subswface Sewage Disposal System•Page 7 of 18
t5insp.doc•rev.712612018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney,Ann Meane ,Robert Delaney,Marjory Fraser,Catherine Resch
Owner Owners Name
information is Hyannis Ma 02601 10/15/2020
required for every Hyannis State Zip Code Date of Inspection
page. cityrrown
D. System Information (cont.)
2. Commerciallindustrial 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.):
❑ Yes ❑ No
Grease trap present?
El Yes ❑ No
Water treatment unit present?
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:
tank pumped for inspection
Source of information:
Was system pumped as part of the inspection?
Yes ❑ No
1500
If yes,volume pumped: gallons
How was quantity pumped determined?
size of tank
routine maintenance
Reason for pumping:
- Title s ofrichaf urpection Fwm:Subsurface Sewage Dieposat system-Page 8 of 18
t5wep.doc-rev.Mrom1s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney,Ann Meane ,Robert Delaney,Marjory Fraser,Catherine Resch
Owner Owner's Flame
information is Ma 02601 10/15/2020
required for every Hyannis State Zip Code Date of Inspection
page. Cityrr'own
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/Aitemative 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:
system installed 6/24/1997 per town records
i
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. 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.):
Joints in good condition, no leakage,vented through roof.
t5imp.doc•iay.7rr"I8 Idle s official inspection forth:Subsurface Sewage Disposal SyStOn'Page 9 of 19
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney Ann Meaney,Robert Delaney Marjory Fraser,Catherine Resch
Owner Owner's Name
information is Ma 02601 10/15/2020
required for every Hyannis State Zip Code Date of Inspection
page City/town
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
®concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain)
t
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑
Yes ❑ No
1500 gallons
Dimensions:
5"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
3'
2"
Scum thickness
7"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
10'
Opened covers and took
How were dimensions determined? measurements
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tank was pumped for inspection and should be done again every 2-3 years for proper maintenance.
Tank was structurally sound and not leaking
7ille s offidel kwmion Form:Subwface Sewage Disposal SYstwn•Page 10 of 18
rs"usp.doo•.rev.1f2812019 I
V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney,Ann Meaney, Robert Delaney Marjory Fraser Catherine Resch
Owner Owner's Name
information is Hyannis Ma 02601 10/15/2020
is
required for every City/To is state Zip Code Date of Inspection
page.
D. System Information (cunt.)
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
Title 5 Oft ial Inspection Form:Subsurface sewage Disposal System Page 11 of 1B
t5insp.doe•.rev.7ris2016
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney,Ann Meaney,Robert Delaney,Marjory Fraser,Catherine Resch
Owner Owner's Name
information is Hyannis Ma 02601 10/15/2020
required for every CitylTown State Zip Code Date of Inspection
page.
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.):
k
*Attach copy of current pumping contract(required).Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
0"
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.):
Distribution box was level and in good condition with.no rot.Water level was even with outlet invert
with no signs of past backup.
Title 5 ofticial Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
t5sisp.doe•_rev.7126=8
Commonweao of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney,Ann Meane ,Robert Delaney,Ma'o Fraser,Catherine Resch
Owner Owner's flame
information is Hyannis Ma 02601 10/15/2020
required for every Hyannis State Zip Code Date of Inspection
page.
yfTown
D. System Information (cunt.)
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.
3 flodiffussers
® leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Title S Ofriciel Inspection Form:Subsurface Sewage MsPosal System•Page 13 at 18
t5q,sp.doc-rev.712WO18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney Ann Meaney,Robert Delaney,Marjory Fraser,Catherine Resch ---
owner Owners Name
information is Hyannis Ma 02601 10/1512020
nis
required for every Hyan State Zip Code Date of inspection
page.
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.):
s.a.s.consists of 3 flodiffussers in a 30'x10'trench. No signs of past overloading,soil and stone
showed no indication of past saturation.No lush vegetation
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 so!ids 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.):
Title 5 official Inspeafon Form:Subsurface Sewage Disposal System•Page 14 of 18
t5insp.doc•rev.7 ISM18
C\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney Ann Meaney,Robert Delaney Marjory Fraser,Catherine Resch
Owner Owners Name
information is H annis Ma 02601 10/15/2020
required for every state Zip Code Date of Inspection
page. City/Town
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.):
r5trts A=•rev.7r2MI8 Idle 5 official Inspedion Form:Subsurface Sewage Disposal SY ttem•Page 15 of 18
- t'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney,Ann Meane , Robert Delane ,Ma dory Fraser,Catherine Resch
Owner Owner's Name
information is Ma 02601 10/1512020
required for every Hyannis State Zip Code Date of Inspection
page- &ifTo—
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
`3 ? Z I 1
i�2 s�l
t5trlsp.doc•rev.M@612018 Tide 5 Ofrccia7 Inspection Forth:Subsurface Sewege Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney,Ann Meane ,Robert Delaney,Marjory Fraser,Catherine Resch
Owner Owner's Name
information is Ma 02601 10/15/2020
required for every Hyannis
page.
Cit annin State Zip Code Date of Inspection
D. System Information (cunt.)
15. Site Exam:
❑ Check Slope
I
❑ Surface water
❑ Check cellar
❑ Shallow wells
12'+
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
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health r explain:
❑ Checked with local excavators,installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation.
Groundwater was established by accessing town of Barnstable groundwater contour maps.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
Titte 5 oftiew Inspection form:Subsurface Sewage Disposal system-Page 17 of 18
t5insp.d6e:•rev:7/28f2018
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
80 Dolphin Lane
Property Address
Linda Delaney Ann Meaney, Robert Delaney Marjory Fraser,Catherine Resch
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/15/2020
page. Cityfrown 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
Mnsp.doc-rev.7'r4s 18 Trtle 5 official Inspection Form:Subeurtaoe Sewage Disposal System•Page 18 of 18
l TOWN.OF BARNSTABLE
I:f ATI N %. /����Ph'i.•� .vim SEWAGE # _ 7',3 6
ILLAGE /�y�N�✓is �a i2T ASSESSOR'S MAP & LOT.26f'03'7
INSTALLER'S NAME&PHONE NO. A)2<A/ ?7.S 7 3�
SEPTIC TANK CAPACITY l SUD 6'i l�o�
LEACHING FACILITY: (type) -3 ZlocvcYFFuS't,Ps
(size)
NO.:OF BEDROOMS '
BUILDER OR OWNER 7#01"VlaS
PERMITDATE: COMPLIANCE DATE:-
Se aration Distance Between the:
1-
Maximum Adjusted Groundwater Table and 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
J
y
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l ` TOWN OF BARNSTABLE
LOCATI Nei 3a 150!/�P��� L��s�= SEWAGE # 9 7 -:3 / 6
VILLAGE �y/�/yr✓�s �o ASSESSOR'S MAP& LOT2C f'O 3 c7
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY J Syd G.q ell LEACHING FACILITY: (type) (size) /0X.'3L> V
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: � a--2-7-COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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
h
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Svc
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ASSESSaRS AMP NO'
No. E" O.' ® -7 Fee
PARCEL N0:
E COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DI SION - TOWN OF BARNSTABLE., MASSACHUSETTS
0ppYication for Migpool *pgtem Con'gtructton Permit
Application is hereby made for a Permit to Construct( )or Repair( an On-site Sewage Disposal System at:
Locan Addrg or Lot No. Owner's Name,Address and Tel.No.
,� p"CO
Installerk Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
s r 3G
Type of Building:
Dwelling . No. of Bedrooms — Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 0?6 2,0 4 %®
coos : x C'�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Hea .
Signe Date ,Z_d(y
Application Approved
Application Disapproved for the following reasons
Permit No. �'" �� Date Issued
7 ` .,.y,..l, '_-s,.-. ^ -r ,.."+rver.•-n.i'"+"r ..ti, ,,; -w+v - .� .-"'.+eti ^ ..rr.."...,,,L.. .,:F ;i'R,�.+ .iYti,,,,et: �s.-
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No. rr� YY 0 '37 Fee
T E OMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DI 1 ION - TOWN OF BARNSTABLE, MASSACHUSETTS
0(ppYication for Mi!6po5ar *pgtem Construction Permit
t
Application is hereby made for a Permit to Construct( )or Repair(,-fin On-site Sewage Disposal System at:
Locatio Addre or Lot No. Owner's Name,Address and Tel.No.
r Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
� �/'ZGy ^��v .✓,j 1" Gam- �I
i
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( ) 1
Other Type of Building No. of Persons Showers( ) Cafeteria( ) I
Other Fixtures
Design Flow L. gallons per day. Calculated daily flow gallons.
Plan Date - Number of sheets ' Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) U!� 2 A %o
iREycA
i
Date last inspected: .
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board of Hea
t Signe Date "
Application Approved
Application Disapproved for the following reasons
Permit No. ��w Date Issued G
THE COMMONWEALTH OF MASSACHUSETTS
` PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
certificate of Compliance - -
!f THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired/re laced( )on
by 2 c is ` ..� f r '74Yo,1,Ass 1�c �3�✓E y
al* 3 3 4�. G,v - has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Constructio it No. j dated 210^
Use of this system is conditioned on co rpliance with the provisions set forth below:
p
No. /� t/�Z7 Fee
k THE COMMONWEALTH OF MASSACHUSETTS
i
j PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
wigoat *pgtem Construction Permit..
Permission is hereby granted to AZ_e- H �
to construct( ,)repair(--Tan On-site Sewage System o ated at 3� �d �' , Z A^'�
f
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or-special.conditions.
All constructions must be completed within two years of the date below.
Date: 4;: / Approved v ,"
i
i
NOTICE: This Form is to be used for the Repair of Failed
Septic Systems Only
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL.
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
h,4— demo,- h- , hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at -3 3 /�v/ice// ..� ��✓ meets all of the
following criteria:
•" Th .e are no wetlands within 300 feet of the proposed septic stem
_ r P Po P system
There are no private wells within 150 feet of the proposed septic system
The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
There is no,increase in flow and/or change in use proposed
There are no variances requested or needed.
SIGNE DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER'
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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