HomeMy WebLinkAbout0094 EDGEHILL ROAD - Health 94 EdgeA I 1 1. load
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Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
94 Edgehill Rd r4'
Property Address a
Filoon-Pratt
Owner Owner's Name
information is Hy annis ort Ma 5/14/19 D
required for every p A
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. Inspector Information Slay ���3s-�--
filling out forms
on the computer,
use only the tab Chad hathaway
key to move your Name of Inspector
cursor-do not HPS
use the return Company Name
key.
P.O.Box
151
Company Address
Forestdale Ma 02644
City/Town State Zip Code
774 274 2581 12866
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
4. ❑ Fails
5/14/19
Inspector's Sign re Date
The system inspector shall s mit ay y of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 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
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is H annis ort Ma 5/14/19
required for every y p
page. Cityfrown 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:
This inspection is not a guaranteeand applies no warrantyof the described septic components in this
report including but not limited to piping structual intergrity of components and life exspectancy of
leaching and described components. This inspection is to describe conditions witnessed at time of
inspection only. Regular tank maintenance and water conservation can prolong life of septic systems
. Information on care and do's and don't's can be found at town health dept or mass.gov
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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•` 94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is H annis ort Ma 5/14/19
required for every Y p
page. Cityrrown 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
1." a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is H annis ort Ma 5/14/19
required for every y p
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is required for every Hy annisport Ma 5/14/19
page. City/Town 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�a
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is H annis ort Ma 5/14/19
required for every Y p
page. Cityrrown 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 aH 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
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is H annis ort Ma 5/14/19
required for every __ Y p
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): as built 5 Number of bedrooms (actual): 6
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550
minimum
Description:
Number of current residents: 0
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
Seasonaluse? Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: unknown
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
I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is H annis ort Ma 5/14/19
required for every y p
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 CM 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: unknown
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
1� 1p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is H annis ort Ma 5/14/19
required for every Y P
page. CitylTown 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 1/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:
1989
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: 2 fe eett
Comments (on condition of joints, venting, evidence of leakage, etc.):
no signs of poor venting or leaks. house is currently under rennovations
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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is H annis ort Ma 5/14/19
required for every y p
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
2'
Depth below grade: Peer
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
1500 gal H10
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10'6x5.5'
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? tape and sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
tees in place level at bottom of outlet pipe no signs of major decay or cracks
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
cam. Commonwealth of Massachusetts
1� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is H annis ort Ma 5/14/19
required for every y p
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
r
cam, Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is required for every H yannis Ort
p Ma 5/14/19
page. Cityrrown 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 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Dbox is solid no major decay level at bottom of outlet
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
f -
Commonwealth of Massachusetts
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is H annis ort Ma 5/14/19
required for every y p
page. CityrFown 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: 2)6'x6'W/3' stone
❑ leaching chambers number:
❑ leaching galleries number:
❑ 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
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is H annis ort Ma 5/14/19
required for every y p
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.):
both pits dry pit 1 Clean with cleakn sand#2 pit was dry with discolored sand at bottom. no sidewall
staining to indicate past failure
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
o
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information isequired or every H annis ort
Ma 5/44/19
page. Cityfrown 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is
required for every Hyannisport Ma 5/14/19
page. Cityrrown 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
_ 2- 39
- q0
0h 00 o
C �
3
wa
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
I� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is
required for every Hyannisport Ma 5/14/19
page. Cityrrown 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: 35'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
lot el. in area of leach pits el.54' low in immediate area 20' bottom of pits 9' below surface
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2618 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
I
Commonwealth of Massachusetts
l? Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
. (� 94 Edgehill Rd
Property Address
Filoon-Pratt
Owner Owner's Name
information is H annis ort Ma 5/14/19
required for every _ _Y p
page. Cityrrown 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
f
7/9/2018 AsBuilt
TOWN OF BARNSTABLE
LOCATION 94 06# N/u- ' SEWAGE #
VILLAGE NS�4-,JAB61 ASSESSOR'S MAP & LOTP?7'/Of�)
INSTALLER'S NAME A PHONE NO. Rae d 8!1d4 6 /arc_ 43Z-oy�
SEPTIC TANK CAPACITY /90
LEACHING FACILITY:(type) , fA A1175 (size) 3/;�- S2Z,AJ6
NO. OF BEDROOMS ✓� PRIVATE WELL O BLIC WATER
BUILDER OR OWNER ie,90 /-71L.00A-1
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
4�
http://issgl2/intranet/propdata/prebuiIt.aspx?mappar=287105&seq=1 1/2
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF - HEALTH
............... .........OF
����5........................................................
Appliration for Dispasal Warks Tonotrudion Frrutit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
system t
06-1_-74-f LL
...... ...... ............................. ........................**...................................................
0&6)4 IL_L t N Addres �& y L
Vilio ......................... ........................................
IC _47 Address
........................... .......................................... ............................... ...............................................
M Installer Address
Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms...............10........................Expansion Attic Garbage Grinder ( )
4
04 Other.—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
04 Other I
...................................................................
.x r person p ................ . s.
gallon Design Flow.......... ......... �ions per per day. Total daily flow... .......................................*........ .. .
Septic Tank—Liquid capacity]) ...gallons Length................ Width................ Diameter................ Depth................
Disposal Trench—No. .................... Width...... .... Total Length.......6.......... Total leaching area...................sq. ft.
Seepage Pit No........2-1..... Diameter...ell... E..'..'Depth below inlet.................... Total leaching area.P0..Isq. ft.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by........................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit................_... Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
04 .............................................................................................................................................................
0 Description of Soil............................................................................................................................................................................
------------ -----------"......... --------
................................................................................ licabl when a ................ ........... ......................
Nature of Repairs or Alterations—Answer wppe... 4-
U -----------------1----7 ............. .............. ..........
........ ..........................................................................................................
Agreement:
The undersigned agrees to install the aforede ib d Individual Se age t Disposal System in accordance with
,
the provisions.of TITLE 5 of the State Sanitary C e The unde -.rsi T rhe agrees not to place the system in
operation until a Certificate of Compliance has been is ed by boar ealth.
��
...............
Si
.............................................................. ............Daje-—----
ApplicationApproved By.............. ........... ............... .. ............................. ........................................
Date
Application Disapproved for the folloui ons:..........................................................................................................---
.............................................................................................................................................................................................
Permit No......... . ...... Issued...........................�.....n
......
Daft
I&
t
0)
No.............._W Fmc.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........r...I.................................................................. ..................
ApPliration for,Disposal Works Tontitrudion ramit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at:
............................................ ...........................................................................
L ociti Add ,o& —
•
V Ve�4 q4 �_7)&E)41L ),
.................. .................
Address
8,
................................................................................................. ................................7..............ws.................................................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder (Other—Type of Building ............................ No. of persons............................ Showers Cafeteria (
Otherfixtures-:.....................................................................................................................................................
Design Flow..................17"" ''"!"'**"'*'...gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid .c"a"pac'ityA ..gallons Length................ Width................ Diameter................ Depth..I..............
Disposal Trench—No..................... Width_................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.. ...... Depth below inlet...............:............Total leaching area_PU,!.�sq. ft.
Z Other Distribution box Dosing tank (
Percolation Test Results Performed by.........................................;................................ Date......_.............:
Test Pit No. I................minutes per inch Depth of Test Pit.........-......._.. Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....--..................
------------------------ -- ...................................
0 Description of Soil................................................:;...................................................................-----....................................................
------
...................................................................................................................................................................................
:4 W--------------
U Nature of Repairs or Alterations—Answer when applicablel. '4...../ .....1).......C/..K...........
-7Qk((�� .. .............. ..... . ........ ......... .... .. ...
Y 6 UJI'77� 7 1 J 5/
........................................................................ .........................................................................................
Agreement: -
/.,I
The undersigned agrees to install the aforedesciib6d Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code 1 The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been(issued by the board of� th.
y
A,�Aoou� U�C:
71
........ . ..
Signed.. ...... ................. ............Date.............
Application Approved By............. .4,
V ............_..._..-Date
Application Disapproved for the follotuifig-reasons:...........................................................................................................--
----------------------------------------------------------------------------------------------------------------
Daft
PermitNo......... .................... Issued.._._�........................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Terfifiritte of Tomphante
THIS IS,TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired (X')
by ................. .........................................................................................................................
Installer. (
a.
............................................. ..........................................................................................................................................
has been installed in accordance with the provisions of TITLE r of The State Sanitary Code as described in 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.......... S_ _1_� - 8 7
..................................................................... Inspector....................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,OF HEALTH
..........................................OF..... L
N ....2-:j� FEE...........---..........
Disposal Works Tanstrurtion Hermit
Permission is hereby granted............ .........r__.0.....lx--..r.....................................................................
to Construct or Repair (>i epair ) an Individual Sewage Disposal System
/-1' c(_ i4). C-00,Z-0
at No..�
....................................................................................................................................................................................
Street
as shown on the application for Disposal Works Construction Permit No??-�& ..... Dated..........................................
............................ .V ................................................ .
-
DATE...........S�.-5=11 U Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
SCOPE OF Y40RK PAGE DRAWING INDEX (j .
1.00 COVER SI IFFT & IN_DUX 1
2.00 FOUNDATION PLAN 2
A)ADD NEYN DOGHOUSE DORMER 3.00 EXISTING IST FLOOR PLAN 3 W
B)ENLARGE EXISTING DORMER 3.01 EXISTING 2ND FLOOR PLAN 4
G)REMOVE EXTERIOR DOOR 3.02 PRO POSED 1ST FLOOR PLAN 5 W
D)REMOVE EXISTING WINDOW 3.03 T'ROPOSF.ID 2ND FLOOR PLAN 6
E)INSTALL NEW REAR FORGH ROOF 4.00 PROP.REAR ELEVATION 7
F)IN5T.ALL NEIN DECK ►�
4.01 PROP. LEFT FLEVATiON 8 ►-.
G)ADD NEW WALL UNDER EXISTING 2ND FLOOR NALL 4.02 EX. FRONT /LEP'F.ELEV.'S 9 +�
H)REMOVE EXTG.CHIMNEY BELOW ROOF/ FALSE CHIMNEY ON ROOF f✓
)REMOVE PANTY/OTHER WALLS IN KITCHEN 4.03 1:{X. REAR / RIGf IT:ELEV.'S 10
REMOVE EXISTING STAIRCASE
5.00 CROSS SECTION - A la ^ i
Ar�Ty}
K)RECONFIGURE EXISTING BATH 6.00 WINDOW SCFEDULP 12
L)ADD NEW BATH OVER OLD STAIRNELL 7A0 3D OVERVIEWS 13
Ml RECONFIGURE OLD BATH INTO NEP4 LAUNDRY 8.00 EX. WALLS OVERLAY PL. IST 14 O f
N)RECONFIGURE OLD BATH 8.01 EX.WALLS OVERLAY PL. 2ND 15
0)REMOVE NALL BETWEEN CLOSETS/NEW SINGLE DOOR
F)REGONFIGURE OLD BATH AND DOORWAYS a o
0)REPLACE SOME EXISTING NINDONS KITH NEW TO BDIF
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1 —I4 E1JGET-FILL DRIVE F�NGNH'NN REQUIRE F
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PAGE-5
q4 EDGEHILL DRIVE HtENREQ�R
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g4 EDGEHILL DRIVE EWHENREQUIRED
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q4 EDGEHILL DRIVE FwHENREp�R of
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ENGINEERS 5TA
q4 EDGEHILL DRIVE -NNHEN REQUIR D
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PAGE-11
q4 EDGEHILL DRIVE E
WHEN REQUIRED
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WINDOW SCHEDULE
FLOOR QTY NUMBER GODE WIDTH HEIGHT R/O DESCRIPTION MANUFAGTURER TEMPERED COMMENTS C)
1 1 W02 WDH2642 31 5/6 " 52 7/8 " 32 1/8"X53 3/8" DOUBLE HUNG ANDERSEN
1 4 W03 WDH21052 35 5/8 " 64 7/8 " 36 1/8"X65 3/8" DOUBLE HUNG ANDERSEN
1 1 W04 GUSTOM 100 " 64 " 100 1/2"X64 1/2" FIXED GLA55 ANDERSEN
1 2 W05 WDH26210 31 5/5 " 36 7/8 " 32 1/8"X37 3/8" DOUBLE HUNG ANDERSEN ILI
1 2 N06 WDH26410 31 5/8 " 60 7/5 " 32 1/8"X61 3/5" DOUBLE HUNG ANDERSEN
1 1 W07 WDH34410 41 5/8 " 60 1/5 " 42 1/8"X61 3/8" DOUBLE HUNG ANDERSEN W N
1 2 N08 WDH2O36 25 5/5 " 44 7/5 " 26 1/8"X45 3/8" DOUBLE HUNG ANDERSEN W Z
2 2 W09 V4DH24310 29 1/2 " 48 7/8 " 30"X49 3/8" DOUBLE HUNG ANDERSEN i
2 1 W10 WDH24310 29 5/8 " 48 1/8 " 30 1/8"X49 3/8" DOUBLE HUNG ANDERSEN
2 3 W11 NDH2452 29 5/8 " 40 1/8 " 30 1/8"X41 3/8" DOUBLE HUNG ANDERSEN
2 8 W12 NDH26410 31 5/8 " 60 1/8 " 32 1/8"X61 3/8" DOUBLE HUNG ANDERSEN
2 4 N15 NDH2646 31 5/8 " 56 7I8 " 32 1/8"X51 3/8" DOUBLE HUNG ANDERSEN
2 1 N14 WDH3846 45 5/5 " 56 7/8 " 46 1/8"X57 3/8" DOUBLE HUNG ANDERSEN Q
3 1 N15 CUSTOM 18 " 501, 18 1/2"X30 1/2" DOUBLE HUNG ANDERSEN }
2 2 W16 WDH21046 35 5/5 " 56 7/8 " 36 1/8"X51 3/8" DOUBLE HUNG ANDERSEN
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NHIENRECtUIR
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PAGE-14
94 EDGEHI'LL DRIVE -w"ENREaURD
HYANNISFORT, MA P&A
N d OGERS&MAR 14EY,INc
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Ro ers&Marne (505)425-6106
HYANNIS FIRE DEPARTMENT
95 HIGH SCHOOL ROAD EXTENSION
HYANNIS, MASS. 02601
RICHARD R. FARRENKOPF BUSINESS: 775-1300
CHIEF Smahe Oeteetord Save eived EMERGENCY: 775-2323
June 8, 1990
7r
(Y
TO UNDERGROUND STORAGE TANK OWNERS:,"'.;';.
This Department is Aware that,you have an und e r g.r oun nk,at.'your-,property
which is over twenEy,,QPyea old
Ts '
According to Federal tate- and Town' ula'
reg tiong..'arrangements must' be,'made
%
for the remov s. We suggest that rior t�,
-al f these p emptying your ,
present underg und,`,tankf'ypu look into having a replacement 'tank installedt
in the basem4-,1 oorkoutt4d',0 the premises, after which time yo U ,w#1 have a';-
V,
period of two years to remove the"underground.� tank.
We have been�j
�4ormedi by,isomd residents that.-'the.-underar underground ta'n� at their.'),
.0
V-
property hashi' e6n :abai7 oned and 'Is`not: in <use.",--�-,---.Th&se tanks shall be-r em8ved
as soon as pp�sfblevf`.",,,
j
J ,
Please do noM -��Sitate, '� `;-)contact this Department if we can
n b o f ur h
assistance orti� y6u,w6LI, d`-dike a listing
sting of some of the. underground tank!
A
anii
removal comp es" i.
q
0
Sincerely,
W.
Ff
RICHARD R. FARRENKOPF, C -------
Chief
Hyannis Fire Department
RRF/dl
CERTIFICATION OF COMPLETION
.. ..._..._..._....._......_.. LL 0
� To: Head of Fire Department Date..._._.
Subject: Certificate of Completion—Installation or Alteration of Fuel Oil Bur
Equipment d
The undersigned hereby certifies that the installation (or alteration) of fuel oil
• burning equipment made under authority of permit ...w^_— dated.:
�• --•---issu _you a appl t in allatiq•�,fors
-16c- ...._ .... ..... V�?� :...-:__
1 J Y
t at - —, __--
- - �•••••••• been made in accordance with
provisions of Chapter 148, G.L.;and re lations made under authority thereof now
currently in effect and pertaining thereto.
I Furthermore, this installation has been tested in accordance with such require-
ments, is now in proper operating condition and complete instructions as to its use and
maintenance have been furnished to the person (or persons) for whom the installation
was made.
The following data applying to such installation is submitted for record:
•
Name ._.__..._ _ BURNER
Mfg. by
Type _._ .„...... ._. _ __... _ or
Model No. Size ._'^ Z
To use not eavier than — _ . __ _ fuel oil
i STORAGE TANK
Type _ _._._.__....._._.__ .__.._._...__.. _ Capacity_._.. . gals. (or) Size___.__..._.._
Location _.._..._.........._...._._......r.._....._ .........._...__. .._.. . .....
_..
Type (automatic or manual) CONTROL
Automatic shut-off valves at burner & tank Installed by
Manual shut-off valve at tank__........__...._
(additional safety devices) Sellenoid—Ferematic. By ..........
77
F e r
HYANNIS FIRE APPLICATION FOR.PERMIT
t �t
DISTRICT; TO INSTALL ;ALTER FUEL OIL BURNING EQUIPMENT'
To the Head'of the if•e Department
Application is hereby made m `accordance iwith the provisions of Cfiap 148.
and,Regulations made under authority thereof by the undersignedfor permit to nstall,a,
alter Por the person or persons and`not the location"named;herpin certain°equipment for.;•
the kQepmg "storage*^or`use ;of fuel;or other mfianmable hgwd products used;=for Yuet'
u as described bel ..........Zt.0712,t;�.-..
4�` ' 11 "�i
ow
NAME
_ T
Description Name'Y
3 Manufact e 42 ~—e
Burner Type'; _ Model>oi• Size
Location% ss Approved No 13 g
Storage Tank. Type?77
w Capacity gals ( ) Size
L777
ocation
a _
Amount of fuel required for testing purpose gals `~
This apphcatiou'is made with full knowledge�bf the current requirements of the
regulations governing.sue installation which will
,be made m coinphanc'e therewith.,
Note If this applicatiou invoh es`alter'ations to`existing equipment,
describe fully on reverse side:
I
CERTIFICATION OF COMPLETION
Date.................. � f�.....12J. ............_...................
.....»._._.
To: Head of Fire Department
Subject: Certificate of Completion—Installation or Alteration of Fuel Oil Burning
Equipment
The undersigned hereby certifies that the installation (or alteration) of fuel oil
iburning equipment made under authority of permit No. ....».......... dated•...................._.......!
issued.by you jnd�a�plying to .the,installation
atfal ...7.�.t�h..FLi«.._......_.....,/. �tl� .................. has been made in accordance. with -
provi us of Chapter 148, G. .,»and regulations made under authority thereof now
currently in effect and pertaining thereto.
Furthermore, this installation has been tested in accordance with such require-
ments, is now in proper operating condition and complete instructions as to its use and
maintenance have been furnished to the person (or persons) for whom the installation
was made.
The following data applying to such installation is submitted for record:
BURNER b
C
Name ._�_9..�_..�f:_........_........................._...--..._...._». 3 d-Zr�L`._7r_.. 0/'�_� ._.._
I
Type .._.........____----- Model No. or Size ....... 1�. .... .__
To use not heavier than .........».. fuel oil
STORAGE TA K• -
PP
Type ..... ..�......................... Capacity, ....1..� gals. (or) Size_...__.....-..._.
Location __(.L,luL). ._��.Q..�l.�lll:l....»� ,X.✓...�.T�ll1. ..._./.. -r.Ll/_�...».._.......__..._.. _
CONTROL
Type (automatic or manual) /�7 ��a`�' p
Automatic shut-off valves at burner & to kGj!;s Installed by L '
Manual shut-off valve at tank......o.`l� ._...._ �/
(additional safety devices) Sellfnoid—Ferematic. By S V .__ _....._ ...
I oYtrZ /�•
%HYANNV FIRE`
APPLICATION FOR RERIVIIT
DISTRICT TO; IN5TALLALTER -FUEL OIL BURNING EQUIPM_EIVT'
To the,Head of the Fiie Department::
Application is hereby made m,accordance with the provisions of Chap. 148, ,G L,
and Regulations'made under authority thereof,by,the undersigned for permit to install
alter for the person or.persons and at the-location.named herein, certain equipment
the keeping, storage or-use .gf fuel or bother. in liquid products used for,Yuel
as describ�eidbelow
lP.! e C
ADDRESS .....'. . ,(.`...;: a�?'°k!
Oescri.ption— Name
Manufacture » -
Burner Type •..s�': Model or Size.:.,. _
Location G! y,Yl,B ::...,, _ Mass Approved Now
Storage Tank: ZYPe> ... Capaci als. zor)Location
......................
Amount of fuel required for testing. rpose!�0;.�,,,,gals.
This application is made with"full knowledge of the current requirements of the•
regulations governing such installation; which will,be made in compliance therewith.
Note: If this application involves alterations: to existing equipment,
describe fully on reverse side:
TOWN OF BARNSTABLE
LOCATION 94 6P6,6f 1-11"- R-0 SEWAGE # 89
VILLAGE ASSESSOR'S MAP & LOTg�Y/'/O-�
INSTALLER'S NAME & PHONE NO. aegp-r 4& a)le- 6 /wc- 43Z-0s�
SEPTIC TANK CAPACITY /mod
Z-(X6 w,nf
LEACHING FACILITY:(type) "-fig' Allr5 (size) 57Z)AI6
NO. OF BEDROOMS S_ PRIVATE WELL O BLIC WATER
BUILDER OR OWNER /-,,-Xo� �'iLOd,t�1
DATE PERMIT ISSUED:
DATE COLIPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
` 7
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TOWN OF BARNSTABLE
LOCATION %�� �+ � SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
' INSTALLER'S NAME & PHONE NO. II olwt �o m-0��o
I SEPTIC TANK CAPACITY JS s9 N/i
I LEACHING FACILITY:(type) (sue)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER y 1'D T1 LG1)J�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: ��-
VARIANCE GRANTED: Yes No �-!
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