HomeMy WebLinkAbout0035 FIRST AVENUE (HYANNIS) - Health 35 First Ave
Hyannis
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.� TOWN OF BARNSTABLE
LOCATION � �� (`�� �. SEWAGE #
VILLAGE_L ASSESSOR'S MAP & LOT
INSTALLER'S AME PHONENOPICbat, �
SEPTIC TANK CAPACITY Q II
LEACHING FACILITY:(type) At (size) Qje, k
`40. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER S 6m'JualueH
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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FOR POOL
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/ EXISTING DWELING
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SHED 1000
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ROBIN c
WILLIAM
W LCox MAPLE STREET
)NO. 3134 i �
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THEE BEST OF MY INFORMATION, "PROPOSED" PLOT PLAN
)KEDGE, AND BELIEF THE HYANNISPORT, MASS
UCTURES SHOWN ON THIS PLAN LOTS 44 & 46, PL. BK. 34 PG. 23
3 BEEN LOCATED ON THE GROUND DATE 713117 SCALE 1"=20'
INDICATE JOB 7881-00 CLIENT PREIS
117 SWEETSER ENGINEERING
203 SETUCKET ROAD
-E PROFESSIONAL LAND SURVEYOR PO BOX 713 SOUTH DENNIS, MA 02660
OFF. 508-385-6900 FAX. 508-385-6991
C: I S8 I PROD 1 7881-00 1 dwg 1 7881-PPOOL.DWG 0 2017 SWEETSER ENGINEERING
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 First Ave.
Property Address
Barry Llewellyn
Owner Owner's Name
iT V1I Ma. 02672 8-25-14
panrtt5p0 �" h 5
information is O
required for
every page. City/Town State Zip Code Date of Inspection
OZ0
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: A. General Information
When filling out
forms on the
computer,use 1. Inspector.
only the tab key
to move your Matthew F. Gllfoy
cursor-do not Name of Inspector
use the return
key. B&B Excavation
Company Name
14 Teaberry Lane
Company Address
Sandwich Ma. 02644
Citylrown State Zip Code
(508)477-0653 SI13640
Telephone Number License Number
B. Certification
certify that I have personally inspected the sewage disposal system at this address and that the
information reported below.is true, accurate and complete as of the time of the.inspection. The inspection
was performed based on my training,and experience in the proper function and maintenance of on site
sewage disposal systems. I am.a DEP approved system inspector pursuant to Section 15.340 of
.Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8-25-14
Inspector's ignature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or.DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection For urface Sewage Disposal Sys elm•Pagl 1 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form '++
Subsurface Sewage Disposal System Form Not for Voluntary Assessments f
°( 35 First Ave. t
Property Address
Barry Llewellyn
Owner
Owner's Name
information is required for West Hy p annis ort Ma. 02672 8-25-14
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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.
i
Comments:
. I
B) System Conditionally.Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon:completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for:"yes", "no`. or"not determined (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
.Y " ❑ N ::. :. : ❑..ND (Explain below):. .
1
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
1
r
Commonwealth of Massachusetts
title 5 .0fficial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 First Ave.
Property Address ;
Barry Llewellyn
Owner Owner's Name
information is
required for West Hyannisport Ma. 02672 8-25-14
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally;Passes (cont.):
❑.Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):I ,
❑ broken pipes) 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):
t
t
°i
❑ 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):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
- the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t&ns-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
35 First Ave.
Property Address
Barry Llewellyn
Owner Owner's Name
information is West H annis ort Ma. 02672 8-25-14
required for y p
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than:100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This'system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or
clogged SAS or,cesspool -
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due:to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
i El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/z day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
�-.
35 First Ave.
Property Address
Barry Llewellyn
Owner Owner's Name
West H annis ort Ma. 02672 8 25-14
information is
required for Y p
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or,privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached.to this form.]
❑ ® The system;is a cesspool serving a facility with a design flow of 2000gpd
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000,gpd.to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
r
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection.
Area.— IWPA)or a mapped:Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
System in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Onspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 First Ave.
Property Address
Barry Llewellyn
Owner Owner's Name
information is required for West HY p annis ort Ma. 02672 8-25-14
every page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"do" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to.the system recently or as part of
this inspection?
® ❑ Were as built,plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for,the condition of the baffles or tees, material of construction,
dimensions, depth of liquid,depth of sludge and depth of scum?
❑ ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location.of the Soil Absorption System (SAS) on the site has
1
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)]
i D. System Information:
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): per Tom
Mullin 3-07
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
35 First Ave.
Property Address
Barry Llewellyn
Owner Owner's Name
information is required for West HY P annis ort Ma. 02672 8-25-14
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Notes on property file taken by Tom Mullin-4 bedroom system
Number of current residents: unknown#of
renters
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® 'No
Water meter readings, if available (last 2 years usage (gpd)):
Detail
Sump pump? _ ❑ Yes ® No
Last date of occupancy.: current
Date
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.):
1
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter.readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°y 35 First Ave.
Property Address
Barry Llewellyn
Owner Owner's Name
infornation is West H anni ort Ma. 02672 8-25-14
required for y p
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
• gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
q.
❑ 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.i Attach a copy of the DEP approval. `
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 First Ave.
Property Address
Barry Llewellyn
Owner Owner's Name
information is required for West Hy p annis ort Ma. 02672 8-25-14
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
unknown- no plans of file
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2'2"
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.):
At time of inspection building sewer appeared to be in good working order no sign of leakage.
Septic Tank(locate on site plan):
1'6
Depth below grade:. feet
Material of construction:
® concrete ❑ metal ❑ fiberglass El polyethylene El 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` 1000 gal.
Sludge depth: 3„
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
1
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
35 First Ave.
Property Address
Barry Llewellyn
Owner Owner's Name
information is required for West HY p annis ort Ma 02672 B-25-14
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.) ,
Septic Tank(cont.) '
Distance from top of sludge to bottom of outlet tee or baffle
33"
0
Scum thickness
Distance from top of scum to top of outlet tee or baffle NS
Distance from bottom of scum to bottom of outlet tee or baffle NS
How were dimensions determined? measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
At time of inspection septic tank appeared to be in working order,Tees present no sign of back-
up.Liquid level.equal with outlet invert.
Grease Trap(locate on site plan.):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions`
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping; Date
t5ins•3/13 Title 5 Official'lnspection Form:Subsurface Sewage Disposal System.•Page 10 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,..'� 35 First Ave.
Property Address
Barry Llewellyn
Owner Owner's Name
information is p
required for y West H annis ort Ma. 02672 8-25-14
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grader
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other.(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
i .
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.):
i
t
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°y< 35 First Ave.
Property Address
Barry Llewellyn
Owner Owner's Name
information is
required for West Hyannisport Ma 02672 8-25-14
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 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.):
At time of inspection d-box appears to in working order no sign of deteration, or carryover.
Pump Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc..):
* If pumps or alarms are not in working order,system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
a
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
SVO,� 35 First Ave.
Property Address
Barry Llewellyn
Owner Owner's Name
information is
required for West Hyannisport Ma. 02672 8-25-14
every page. City/Town State Zip Code Date of Inspection
D. System Information (Pont.)
Type:
® leaching pits number:
2 6'x6'
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At time of inspection leaching appears to in working order no sign of hydraulic failure. Pit 1 dry at
time of inspection.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication.of groundwater inflow. ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
r
j
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 First Ave.
Property Address
Barry Llewellyn
Owner Owner's Name
information is West H annis ort Ma. 02672 8-25-14
required for y p
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition,of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y� 35 First Ave. I
Property Address
Barry Llewellyn
Owner Owner's Name
information is
required for West Hyannisport Ma. 02672 8-25-14
every page. City/Town State Zip Code Date of Inspection .
D. System Information (cont.)
Sketch Of Sewage Disposal System::Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100'feet, Locate
where public water supply enters the building. Check one of the boxes below:.
hand-sketch in the area below
drawing attached separately
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IS:ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
i
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System.Form Not for Voluntary Assessments
y 35 First Ave.
Property Address
Barry Llewellyn ,
Owner Owner's Name
inquired for
is West H annis ort Ma. 02672 8-25-14
required for y p
ev_ry page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
>8'6"
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high groundwater elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: pate
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local,Board of Health -explain:
Previous inspection hand hole aguered to 8'6"with no ground water
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high groundwater elevation:
Augered hand hole
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
35 First Ave.
Property Address
Barry Llewellyn
Owner Owner's Name
information is
required for West Hyannisport Ma. 02672 8-25-14
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: A, B, C, D, or E checked
E Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
E System Information'— Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
R
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t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
09/g9/2006 SAT 9:31 FAX 508 775 9222 002/012
' UOMMONWEALTH OF
EXECUTIVE MASSACHUSETTS
IVE OFFICE OF ENVIRONMENTAL FAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION k�"
OFFICIAL, INSPECTIONTITLE S 1
FORM_NOT FOR VOLUNT
SUBSURFACE SEWAGE DISPOSAL SYSTTEY FORMASSESSMENTS
PART A
CERTIFICATION
Property Address: 2-
Owner's Nana:
Owner's Address: 2 1 C "
Date of UsPection:� y
Name of In ---"-
Com Spector• ease print) <
paIIy Name:
M"Wng Address: �.
Telephone Number: 26C�j R
CERTIFICATION STATEMENT
mfy-that I have penonall
below is true y inspected the sews a disposal s'accurate and complete as of the 8 of the Ystem at this address and that the info
apt approved d experience in the proper function�mainte inspection.ce The inspection was performed baassed nreported
system inspector pursuant to Section IS.34d off Title
lof on e Ip sewage my
n .Oisp Th e system:sal systems.I am a DEP
Passes CM 1S
Conditionally passes
Needs Further y the Evaluation b
Fails Local Approving Authority
Inspector's Signature
DaterThe system inspector shall submit a
DEP)within 30 days ofcompletin COPY Of this pection report to the A
gPd or greater, the S this inspection.If the system is a shared
Authority(guard of Health or
DEP.The on inspector and the system owner shall submit the r hared system or has a design
authority.should be sent to the system owner report to the app p flow of IO,p00
and copies sent to the buyer,if applicable.rt eg�d e of the
Notes and Co approving
minents
-Re -\Cri6
PQ
This report only descrihes.conditions at the time O�
time. This inspeCnon does not address how the system will
of Inspection and under the conditions of use at that
conditions of use.
Perform in the future under the same or different
Title 5 Lnspection Form 6/15/2000
page I
09/D9/2006 SAT., 9:31 FAX 508 775 9222 003/012
OFFICIAL INSPECTION FORM
. � SUBSURFACE SEWAGE SYSTEM T`�.RY A.SSESSNENTS
PART A INSPECTION FORM
Propert3►Address:
CERTIFICATION(continued)
�J�J
s� �Iry
Owner:
Date of inspection:
�
Inspection Summary: Check
A'B'C'D or E/pi-�Y3 complete all of Section D A- System Passes:
—� y inf
I have not found an
i 5.303 or in 310 C11IIt 15.304 eexrmt.q�which irulicates that any of the failure criteria y failure criteria not evaluated are ' -desc 3i0 CMR
C eats: indicated below.
B• System Conditionally Passes:
One or more system components asthe�.
Zepaired' A IIpon completion of the rVlaceMCat or Conditional Passe section need to be replaced or
syste
repair,as approved by 1 the 8o f Health,Will pays,Answer Yes no or
explain . t determined MN ND)in the
for the following statements. "not dete
rmincd"please
The septic tank is ale and over 20 e *
unsound,exhr'bits substantial' years old or the septic tank
er
existing tank is replaced with a co lion or exmltr'ation or tank failure is or not)is stzuchuaily
A metal
that theptic e win p if i �septic tan as approved by Board of IIcalth.sy-ste win P inspection if the
indicating than 20 e
tank is less Y old is available. �' t leaking and i fa Certificate of Compliance
ND explain:
_____ Observation of sewage backup or break out
obstructed pipes)or due to a broken,settled or A static water level in
approval of Board of Health): or Zen iribution box.System the will assdistrib inspection
on box due to broken or
Pis u�spectioa if(with
brolrcp plpe(s)are replac
o� ctioa is removed
distribution box is leveled or
ND explain: r laced
The system req Zppunjping more than 4
Pass inspection if( 'thrapproval of the Board of Heaes lth): Year due to brokers r obstructed pi e s ,
� P O The system will
broken pipes)are replaced
obstruction is removed
ND explain:
T41 ; i.,�..o..►...., c.,.,„ ,sir c��nnn
09/i 09/2006 SAT 9:32 FAX 508 775 9222 f004/012
' t -
OFFICIAL INSPECTION]FORM.NOT FOR VOLUNTARY
1 SUBSURFACE SEWAGE DISPOSAL,SYSTEM INSPECTSESSMENTS
PART A ON FORM
CERTIFICATION(continued)
�PertyAddress• c�, �- {�J
Owner:
Date of Ins on ��
Pectlon.
C. Further Evaluation is Required by the Board of Health:
is tiom exist which require further evaluation b
f8 otcct public health,safety or the environment,the Board of Health is order to de
e if the system
l' System w ass unless Board of Health determines in accordance with 0
system is no unedoning in a manner which wilt protect public held safetyC M 15303(l)(b)that the
and the environment:
spool or P is within 50 feet of a surface water
Cesspool or pri within 50 feet of a bordering� derinS vegetated or a salt marsh
Z' S' UO;Will fail unless the Hoard of
system is functions In a alth(and bile Water Supplier,if sin
manner that rot r m nt.-inq that the
.--1 P the ub11c health,safety and environment:
The system has a septic tank and soil ab
surface water supply or tnlutary to a surface wa tionsystem(SAS)and thly. e SAS is within 100 feet of a
The system has a septic tank andSAS and the S
within a Zone I of a public water supply.
- The system has a septic and SAS and the SAS is
50 feet of a private water supply well"
.,.... The system has a septic and
1 SAS and the SAS is less 100 feet but SO feet or more from a
Private water supply well* ,
Method used to determine distance
*''This system passes " the well water anal
bacteria and volatil rganic co analysis,Performed at a DEP c ed laboratory,for coliform
f the presence of nVo�indicates that the well is free fro Itution from that facility and
failure criteria ma nitrogen and nitrate nitrogen is equal to or less
triggered"A copy of the analysis nuW be attached to this fo5 PPm,Provided that no other
3• Other:
i
1
Titlo lncnwrti�n Fnrrn�/1 c/7nnn
3
09/09/2006 SAT 9:32 FAX 508 775 9222 U 005/0J_2
1
OFFICIAL INSPECTION FO
SUBSURFACE SEWAGED NOT FOR VOLUNTARY ASSESS
DISPOSAL SYSTEM INSPECTION FOBS PART A
CERTIFICATION(continued)
Property Address: S f- e
Owner:
Date of�s on t
pecti : �
D. System Failure Criteria a
You mu indicate Pplicable to all systems:"yes"or`no to each of the following for alai inspections:
' Yes ,N
_- —7- Discharge
of sewage into
facili ysiem co
�L age or t3'ors mponent due overloaded of clo
cloggedponding ofei�]uent t the sine of cite ground or surface watersg�SAS or cesspool
SAS or cesspool due to an overloaded or
-� Static liquid level in cite distribution box above outlet invert
cesspool
quid d due t as overloaded or clogged SAS or
. ���cesspool�less than 6"below invert or available
.._.. .
volunw is less than�4day now
of tunes Pumped
more than 4 times in the last year NOT due
et clogged or obstructed Pipes N
Any Portion of the A,c"ypool or Privy ) Number
Any portion of cesspoolp vy is below high ground water elevation.
water svoy. or Privy within 100 feet ofa s>trAtce water supply or tributary to a surface
-- Any portion of a Cesspool or
— Any portion ofa cesspool or Privy s a Zone 1 of a public well
Any portion of a cesspoolp�is less SO feet of a private water supply well.
Weater
apply well no
or n than J00 feet but
performed a!a DEP certified Bed laboratory,qhty anal than SO feet from a private water
[This system passes if the welt water analysis,
indicates that the well is free from for coution m that bacteria and volatile organic co
nitrogen and nitrate nitrogen is equal o or less tb that tacili ammonia
�unds
are triggered-A ca hr and the presence of
gg py of the analysis must be attached tot force,provided that no other failure criteria
A-0 (Yes/No)The system fails.I hav
+ d bed in 310 C 15.303 de
that one or more of the above failure criteria exist as
Health to determine what will be system fads,�system owner should contact tht Board of
ary to correct the failure.
E. Large Systems:
To be considered a large
gpd. t; system the system must serve a facility with a design You must in a either"Yes"or"to"to each of the following. ga now of 10,000 gp to 15,000
(The following exit a ply to large systems in addition to "
Yes no.
the criteria above)
the system is within 400 fee
surface drinking water Q
the system is ply
y within 240 feet of a hibu
a s 'ace drinbrig water supply
the system is located in a
Zone H ofa nitrogen sensitive area(bate Wellhead Protection Area—
pu6lie water suppi well IWPA)or a mapped
' Ifyou have answered"yes"
sYes"in Section l?abo the large system has faileuestion in d n E the system is considered a "significant threat er Sectio , The owner o 'ftcant Feat,ar ans
n E r operator were
15.344. the s s em o or failed under Section D shall upgrade P ator of any large rem considered a d
y weer should contact the appropriate regional f thef D stern in accor
with 310 CUR
' eP�nent.
Title S f„annnhi�n �,,....,�n<i�nnn
4
09/09/2006 SAT 9:32 FAX 508 775 9222
006/012
OFFICIAL INSPECTION FORM
NOT FOR SUBSURFACE SEWAGE DISPOSAL SYS EM INS ECTION FORM
ASSESSMENTS
PART B ION F
CHECKLIST
Property Address: c�3S
Owner:�n
Date of Inspection:
Check if the followin have been dose.You mast indicate' es"or"no„as!o each of the followin ,
Yes No
Pumping information was provided by the owner,occuPank or Board of Health
Were any of the system comPoncnts Piped out in the previous two weeks?
_ Has the system received normal flows in the Previous two week period?
Have large vohimes of water been introduced to the system recentlyor 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 sig
ns of break out?
Were all system components,excluding the SAS,located on site?
Were the septic
of the battles or tee talk manholes uncovered,opened,and the interior of the tank.
V s,material of construction,dimensions,depth of Liquid,depth of sludge and ed for the condition
Was the facility owner depth of scum?
maintenance of subsurface sews c disposal
if different from OwneF
g posal systems? )Provided with iafornuation on the proper
The size and location of the Soil Absorption System(SAS)on the site has been
no determined based an:.
Existing information.For e J xample,a Plan at the Board of Health.
�l Determined in the field(if any o
is unacceptable)(310 CMR 25.302(3)(b)J f the failure criteria related to Part Cis at issue approximation of distance
Titles C Tncnn.tinn i.'nrm !./)���nnn
09/09/2006 SAT 9:33 FAX 508 775 9222 Z007/012
OFFICIAL INSPECTION FORM
SUBSURFACE SEWAGE pOS g
NOT FOR
VOLUNTARY ASSESSMENTSS EM IN
PART C SPECION FORM
SYSTEM INFORMATION
Property Address;,?�� ���j- � l,e
Owner: �.
Date of
Insp dop.
RESIDENTIAL, FLOW CONDITIONS
Number of bedrooms(design): R
Z Number of bedrooms(actual):
DESIGN flow
based on 310 CM$,15.203 fore )Number of current residents: ( example:l 10 gpd x#of bedrooms):
IDoes s residence have a garbage grinder(yes or no): V\-0
SLaundry on a separate sewage system(yes or no):�t[ifyes separate inspection required
item inspected(yes or no): ]
Water meter r(yes or no):�C�.
dings,if available(last 2 years usa e
SumpPMP(yes or no): � g (gPd)k—_
Last date of occupancy,.�V v f"•
TODRbANDUSTRIAL,
Design now(bt 10
C�JR 15 203 :
Basis of design flow(sea ) and
��two tee�(yes or no):_ �eLc.):
Non rani holding tank present(yes or
tary waste discharged to the Ti e-S
Water meter readings,if avaal'abie�� item(ye �.
Last date of occupancy ✓
O esenbe):
Pumping Records GENERAL INFORMATION
Source of information:
Was system pied as part of the ins _
If yes,volume petition(yes or no):
Pumped:
-gallons
Reason for pumping. --How was quantitypumped umped et ed?
TIVPE 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,Ianovative/Alteraative techaolo if any)
obtained from system owner)technology.Attach a copy of the current operation and maintenance contract(to be
_ Tighi tank Attach a copy of the DEP approval
Other(describe):
Approxunate age of all compo eats, date installed if
( known)and so�of�norrmation:
N.
Were sewage odors detected wh n arrives\ at the
g e site(yes or no):�o �
Title G 1ner�o�Finn �+nrr„r./T C/7(�nn
6
09i;09/2006 SAT 9:33 FAX 508 775 9222 U 008/012
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARy AS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTi N FORM[
MRM
ON FO
PART C
SYSTEM INFORMATION(continued)
Property Address• . S fi v�
Owner: UCc �c`�
Date of Inspectloa:
BUILDING SEWER(locate on site plan
Depth below grade:
Matcriajy of cons
trucctioon �,yE iron �4p PVC
Distance from pnvate water —other(explaia):
Comments o co supply well or suction Line: �,ct t�
( on�f joiata,vent' evi4rce,of le ge,
SEPTIC TANK;_(locate on site plan)
Depth below grade:
41~ cc
Material of construction:�Ico=eta
"mew--fiber81ass.polyethylene
If tank is metal list age: is agc confirmed b a certificate) I { Y Certificate of Compliance(yes or no
_ Dimensions: )•_(attach a copy of
Sludge depth: �J
De from m top ofsludgc to bottom of outlet tee or baffle: t1
Scum ce Imess:}�_
Distance from top of scum to tap of outlet tee or baffle:
Distance from bottom o m to bottom oscuf�oueei�tee or baffie• I
How were dimension detcrn�d,�-� tQQ C1 —I l S Comments(on pumping recommendations,in le as rela d to utlet' t and outlet tee or b ditio
vert;e�n'denca ooaf llieaka e,etc.}: awe conq structural rote
gtitY,liquid levels
GREASE TRAP:____(locate on site plan)
Depth below grade-_
Material of construction:_�
(explain): metal fiberglass __polyethylene o
Dimensions:
Scum thickness•
Distance from top of scum o top oa�f oou et tee or baffle;
Distance from bottom°f sc bottom of outlet tee or baf33e:�__
Date of last pumpin :�`�
Comments(on tng recommendations,inlet and outlet tee or baffle c
as related to outlet iuve condition,structural is
evidence of leakage, etc.): liquid levels
I
I �
'i�r1a;inctnrtinn Fnrr„�./t f/'7nnn
7
}
09/09/2006 .SAT 9:3 3 FAX 508 775 9222 16 009/012
OFFICL L INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:�S �- .��.�
Owner: �v�
Date of Inspection: 0
GHT or HOLDING TANK•
(tank must Depth bel be PumPed at time of inspection)(locate on site p an)
ow .
Material of constructio , concrete
imtal_ fiberglass
Dimensions: ]one other(explain):
Capacity:
Design glow: Notts
afi,4/da
Alarm present(Yea or noj; Y
Alarm level: arm in working
Date of last• � order(yes or no):
Co (condition of alarm and float switches,etc.):
D"STMUTION BOX:1( Prescnt must be/ opened)(locate on site plan)
Depth of liquid level above outlet invert 0 ct
C-oanments(note if box is level and distnbution to outlets equal,any evidence of solids c over
leakage into gr out of bo 4 _
_\ 21tc)• Y ,any evidence of
P INA
CHAER_ (locate on site plan)
Pumps in working of
Alarms in wonting order�es or no):
Comments note condition or no
MB
):��
( edition ofpump chamb
condition of umpp -, - aces,etc.):
�.
T41-c
a
r 09/09/2006 SAT 9:34 FAX 508 775 9222
Z 010/012
OFFICIAL INSPECTION FO
� SUBSURFACE SEWAGED pOSAL SYSTEM ASSESS
INSP NOT Foll C ON Fps S
PART C
SYSTEM INFORMATION(continued)
PrVe1•ti'Address: ,
Owner:
Date of Inspection: p
O
SOLI,gBSORpTION SYSTE
(locateonsiteplan,ezcavation not required)
1fSAS not located expZ-3-4—�(SAS):
wh :
T
eachin8 pits.number:2
eaehtag chambers,numlxr•
leaching galleries,number.
— Ieaching trenches,number,length-
number,leaching fields, dimensions:
overflow cesspool,number
innovative/alternative system
oetc mmenh(note condition ofsoil, off oftechnology;
hydraulic failure.level of PO damp soil,condition of vegetation,
A11
SSPOOLS: (cesspool
mnat be pumped as part of inspection)(locate on site plan
Number and a tion: )
Depth—top of liqui • et invert:
Depth of solids layer;
Depth of scum layer
Dimensions of cesspool:
Materials of construction:
Indication ofgroundwater inflow
Comments(note condition of soil, es or no):
,signs of hydrae q Level of
pondrag,condition of vegetation,etc.):
PRMY:— (locate on site )
Materials ofconstruc
Dimensions:
Depth of soli
Comments ote condition of soil,signs of hydraulic failure, level ofponding, condition of vegetatio etc.):
9
' 09/]9/2006 SAT 9:34 FAX 508 775 9222 U 011/01?
Page 10 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM WORMATION(cominued)
Property Address-
�Y
(Nmer. —
cG�!\2
Date of Inspection:
SXETCH OF SEWAGE DLSPOSAL SYSTEM
sposal system iacludatg ties to at least two petmanezzt reference
bmchmaft. Lacaae all wells within 100 feet Locate where laudmatics°�
Provide a sketch of the sewage di
public water supply eaters the building. -
Cum
. [3
Zit 32 l4 �
in
09/09/2006 SAT 9:34 FAX 508 775 9222 Z 012/012
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT ION FOR
M
PART C
SYSTEM INFORMATION(continued)
Property Address: eJ V
Owner:
Date of Inspection•
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water `rZ eet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:Observed site(abutting property/observation hole within ISO feet of SAS)
Checked with local Hoard of Health-explain.
Checked with local excavators,installers-(attach documentation ,
Accessed USGS database-explain: t ` 3 2. .O�e
y u mast describe how you estab ' high grp d wat elev Lion: #
T 41- S Tncnortinn Fnrm /.!i C/�nl�/1 11
r
ul i 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUN'rARy ASSESSMENTS
� SUBSURFACE SEWAGE DISPPART
SAL SYSTEM INSPECTION FORM
TB
t CHECKLIST
Property Address: YX
Owner: -� �..�
Date of Inspection:
Check if the following have been done.You must indicate' es"or"no"as to each of the followin .
Yes No
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out is 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 in
spection?
Were as built plans of the system obtained and examined?
(Ifthey Were not available J 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,
of the baffles or tees,material of construction,dimensions, d'and the interior, of the tank inspected for the condition
/ 1Om'deP�°f liquid,depth of sludge
t! 8 and depth of scum?
_ Was the facility owner(and occupants s 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 determine
Yeas no d based on: -.......
Existing infonuation.For example,a plan at the Board ofHealdL
_ Determined in the field(if any of the failure criteria related to P
is unacceptable)(310 CMR 15.302(3)(b)j ait C is at issue approximation of distance
T;tio� inenocYinn Fnrm S/3 Qi7/�(►n S
LOVT000 ZZZ6 5LL 902 Xy3 8Z:6 LLVS 900Z/60/60
I
r nsc V CJl 1 1
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION OMENS
PART C FORM
SYSTEM INFORMATION
Property Address:.S`�—
Owner: ---
Date of eft
Inspection:
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): Number of bedrooms(actual
DESIGN flow based on 310 CMX 154203 fore )'
Number of current residents: ( example: 1 I0 gpd x#of bedrooms);
Does residence have a garbage grinder(yes or no):V a
Slaundry on separate �e r no) or no):V�C� Yes karate inspection reyuiredj
Seasonal use:(yes or no):L,0.
Water meter readings,if available(last 2 years usage(gpd));
Sump Pump(yes or no):,�b
Last date of occupancy:.F^Q �
COMMERCUL INDUSTRIAL,
'l)Te'e a ushmenti:
Design flow(has 10 CMR
Basis of design now(sea and
sgfl;etc.}:
Grease trap Pent(yes or no):
Industrial waste holding tank present(yes or n
Non-sanitary waste discharged to the Tit
Water meter readings,if avaff b f/ item(ye
Last date of occupancy
O escnibe):
Pumping Records GENERAL INFORMATION
Source of information:
Was system pumped as part of the inspection(yes
Reason for p gOns—How was quantity Pumped ete d?
Y1 Gam` Y1�P���
�E 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)
____Tight tank __._Attach a copy of the DEP approval
_Other(describe):
Approximate age of all co mpo en, to' tai
led(if known
� )and source of informat�on�
Were sewage odors detected U� C.G�
when arriving at the site(yes t
or no):��
TitJp f TrcnP`•finn Fnran F!�[/'1'(1/1(1 6
LOO/Z00 2 ZZ96 SLL 909 XVJ 8Z:6 JNS 900Z/60/60
1.
\ O� FASPECTION FORM—NOT FOR VOLUNTARY�
CE SEWAGE DISPOSAL SYSTEM INSPECTION OSESSRM
PART C
SYSTEM INFORMATION(continued)
Property Address; �j�
Owner:
Date of Inspection;
BUMDING SEWER(locate on site plan)
Depth below grade: Z c�t r,
Materials of construction: cast iron PVC
Distance from private water supply well or suction line.other(explain):
Comments(oft co ' 'on�joiab,ventin eyi
SEPTIC TANx:__(locate on site plan)
Depth below grade:
Material of construction: •concrete__ me
—other(explain) tal—fiberglass____polyethyleno
If tank is metal list age:_ is age conrnmed b a C
certificate} t y ertifiCate of Compliance(yes or no):_(attach a copy of
Dimensions:
Sludgedepth
' Distance from top of stud a to bottom of outlet tee or baffle: _
Scum thickness:
Distance finrn top of scum to top of outlet tee or baffle: !
' Distance from bottom of scumto bottou>t oflouee-tec or baffle._U_!11 ''� How were dimensions determined;
Comments(on pumping zecommenda 'o ,inlet and outlet tee or biiMhe condition,strut
as related to u$et' ve,eviclFace of I aka etc.)� structural irate �
V� �.° � B�tY.1i d levels
GREASE TRAP:____(locate on site plan),
Depth below grade: :.
Material of construction: co metal
(explain): ---- ___fiberglass
_polyethylene o
Dimensions-
Scum thickness•
Distance from top of scum of top of et tee or baffle;
Distance from bottom of sc o bottom of outlet tee or baffl�'e:`—Date of last pumpin
Comments(on ing recommendations,inlet and outlet tee or baffle condition,stn,c \
as related to outlet invert,evidence of leakage,etc.): tural i�ty,�
liquid levels
I
A
Title 1 r.0—ptin" Fnrm r./r q/7nnn 7
0
G00/E00 ZZZ6 SLL SOS XVd 6Z:6 1VS 900Z/60/60
rage a of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
RM
SYSTEM INFO T C
INFORMATION(continued)
1ZMA
Property Address:� `� -{�
Owner: C..�
Date of Inspectfon: Trn
GHT or HOLDING TANK: (tank must be Pumped at time of inspection)(locate on site Ian Depth below Pun)
Material of construct-o , concrete
metal fiberglass
yIeae Di ions: other(explaia):
mens
Capacity: lions
Design Flow. day
Alarm Pent(yes or no):
Alarm level: am in working order
Date of last ins: (Yes or no):—
Co {condition ofalarm and float switches,etc.):
I
DISTRIBUTION BOX•• t(if presen must be opened
)(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distnb equal,to outlets leakage into Qr out`f box,etc.): Qom,any evidence of solids c
e. arryover,any evidence of
PEER: (locate on site plan)
_....-------=------�`a.+yaB..lTl--17YAIlCIn$OIdeF-(i/eg•Or-riO��-- -----•-•----._�.�__.._....._..------__..�_.__—_____.._..._..__—__.----
Alarms fn working order(yes or no):
Comments(note condition of pump c�—
condition of pumps and a'pp
UdCR�nces,etc.):
I
i
Tielo i "na";nn 9—"
a
000/v00[n 9ZZ6 SLL 909 XVd 6Z:6 .LVS 900Z/60/60
I
rage V of f i
OFFICIAL INSPECTION FORM—
NOT
FOR
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSVOLUNTARY
CYO SESSMENTS
PART C ON FORM
SYSTEM FORMATION(continued)
PropertyiAddr-e's►s: �
Owner:
Date of Inspection: Z
SOIL ABSORPTION SYSTEM(SAS): (locate on site la
P a,excavation not required)
If SAS not located explain why:
T��
leaching
Pik number:2
lung ehanlbwT,number.
teaching galleries,number.
leaching trenches,number,length:
leaching fields,number,
overflow cesspool,number; ons:
innovative✓altmwive systems
CouunenL�(ante condition of so' signs Type/name of technology:
etc.): ik gns ofhydraulic failure,level ofpondin
&damp soil,condition of vegetation,
SSPOOLS: (cesspool must be
Posed as part of inspection)(locate on site plan)
Number and c tion:
Depth-top of Iiqui et invert:
Depth of solids layer:
Depth ofseum layer:
Dimensions of cesspool:
Indication of groundwater inflow(yes or no):
Comments(cote condition of soil,signs of hydraulY 1
e,level of lmndiag,condition of vegetation,etc.):
PRIVY: (locate ou site �\
Materials of construc '
Dimensions:
Depth of soli
Comments ote condition ofsoil,signs ofhydraulic failure, Ievel ofpondin
8,condition of vegetario etc.):
Ti;lo S 7ncm—tine X'nr—r,11 S/,)nnn
9
L00/200In ZZZ6 5LL 902 XVd 6Z:6 JNS 9009/60/60
Page 10 of l i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMEN3'S
PART C
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
SYSTEM INFORMATION(continued)
Property Address-
Owner.
V1I
Date of Inspection- 7
SI{LTCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pamanem
benchmarks.Locate all wells within 100 feet Locate where public water supply eaters thee building.
�t�rks ar
1 3'
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L-00/90012 ZZ96 SLL 909 XNd 0£:6 JVS 900Z/60/60
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: l
Owner: Y�
Date of Inspection: �s
SITE EXAM
Slope
Surface water
Check cellar
+ Shallow wells
Estimated depth to ground water J>!2 eet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 15o feet of SAS)
Checked with local Board of Health-explain-
Checked with local excavators,installers-(attach documentation);
i Accessed USGS database-explain: jLNQ 1 y, p��
Y u must describe how you estab ' high'•� S �' rid wat elev tioa: t
`� .k t V\
t ! le
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LOCATION SEWAGE PERMIT NO.
VILLAGE _
6� I
A & B CESSPOOL SERVICE
128 BISHOPS TERRACE, HYANNIS, MA 02601
BUILDER OR OWNER
f
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
r
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No...1�.. .� Fin$......y _
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appfiration for Dispnlia1 Warks Tomitrurfintt Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( c.}--j!f Individual Sewage Disposal
System at:
.....--...Z.S..._.1............A:............................................... --....-----•.�+ = - �`wwo s - .......----
ation.Add ess or Lot No.
N� `P............. .t.c..ca�� r���!r-�........... .................
Owner Address
--•• . .. ..------. .........-••---.• --•-elk-......- Y....
Installer Address
Type of Building Size Lot-.____•--••---•-------•----•Sq. feet
Dwelling—No. of Bedrooms---.-.3----------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Building ............... No. of ersons---------------------------- Showers — Cafeteria
Pa yP g ------------- P ( ) ( )
a' Other fixtures ----------------------•---•-----
W Design Flow.......�` .....................gallons per person per day. Total daily flow......_ .....................gallons.
W ' Septic Tank—Liquid capacity............gallons Length................. Width................ Diameter--.--.-------.-- Depth................
x Disposal Trench—No..................... Width-------------------- Total Length.................... Total leaching area...................sq. ft.
Seepage Pit No--------------------- Diameter--._--_-.-.--.---- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
,.a 1
,�. 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...............................................................................-------------------------------------------------------------------------------------•.
W
U Nature of Repairs or Alterations—Answer when applicable_ Yv�`? `.......I- ------1�.- ..�P
�a r.. ;------------------------------------------------------------------------------
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 Cerj,,,..'(Signed
to of Compliance has ben iss the and of health.
-------- -- ---- --- ......................... -------- ............................... ---- 1"' r..
Date
Application Approved By -- ---- ---------- -------- ---------------------- ---_ ------ Do w
Application Disapproved for the following reasons- ...................................................................................----------------------------------
= ----------------- -------
n Dae
...........
- --------------------------------------- ----------------------------------------
Permit N
` Date
Fim........ .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
' L TOWN OF BARNSTABLE
Appliratilan for lliipniittl Works Tnnitrnrtion ramit .
Application is hereby made for a Permit to Construct ( ) or Repair ( )—afr Individual Sewage Disposal
System at:
......................... ....................................7«...wV�e�_,.b 1rc'r ............-
Location-Address -.- or Lot No.
�t �_�_. � o.►v c�r— ............... ..........__....
owner Address
w \A rP+a s 1Q , CZ P a� (`J V , • YLt� 1(
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms---------- ..................... .Expansion Attic ( ) Garbage Grinder ( )
Other T e of Buildin No. of ersons............................ Showers — Cafeteria
P1Other fixtures ----••-••--•......--•---•------- --•••---• •---•-' -------•---•=••-••••-••••••••......•-•••••-••-•---•••-•-••-••-••••-•-•.........••-
' Design Flow......._•r�:...,._.. .gallons per person per day. Total-daily flow............... gal
w - '�--------------------- ...��--------------•----- Ions.
:r a
' Septic Tank—Ligmd ca.paclty.....__.,...gallons Length ............... Width................ Diameter---------------- Depth_...__......_..:.
Disposal Trench—No............:........ Width.................... Total Length...................... Total leaching area-___w.__«.__...,-.sq. ft.
Seepage Pit No------------------- Diameter.___._•-•___-__-_-_- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) s
~' Percolation Test Results Performed bY4*........................................................................ 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...................................................................................................................................................................... `
x
------------------------•------------------•--------------------------------------------....------•-----•-----------------------••-------------------•-------•------. ••-•-•......---------._.......
U Nature of Repairs or Alterations—Answer when applicable - � 1`A�.........1AM!....... `_�..�*_-..?!'�_`
--_ — _ v
/a 1Gth-----� ---' -----------�s_ _�:_� ........................�.. O C .................
..............y.-- ................ ��..........__••_•`�-ram ......__._...__...._._......................._......._.....
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 has been issued-by-the board of health.
Signed -----------------------------------------•------------------------------ ------/---
L, .............................. Date
Application Approved By .... .. .... .-.• ... ----------------- ------� e2j� ... �1
Application Disapproved for the following reasons: .......................
------------------------ --------- ----------------------- -------- ....................................................................................... ........................-........... .........I..............................
Date
Permit No. ..-.z./.L. ? ........ ... G Issued ----...'---------------�-e----- ............. -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C'Iextift ate of (10mFXiance
y
THIS IS.-TO-CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (
G + -IPI -ltlry�f ... -,-Ica r ................................by -----------................-------- -----
y Installer
kA
has been installed in accordance with the provisions of TITLE 5 of The-State Environmental Code as'described in
the application for Disposal Works Construction Permit No. =ft - 2.. .�,-.......... dated ... .. .........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONST �UED AS A GUA <ANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE�."?..-�....... ..9® f' '... Inspector "-
---....... ......... .G ...................... ......................
5
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
IA PP
TOWN OF BARNSTABLE
Disposal Iforks Tunstnution Vlermi#
Permission is hereby granted........::.%A.��..���::�---. 15*' 2�.L--..._....... ...............................
to Construct ( ) or Repair ( 1)_an-Individual Sewage Disposal System
at No..................'� .�... „Ar v� 1 .....`� ,...,u�-:.........�..............------.............----................
A---
Street
as shown on the application for Disposal Works Construction Permit No..q -� `? Dated...... .........
...
DATE. �/.. � `�r� Board'ofH�th_6 j
7. . .......••--•.........................•----...... G
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS