HomeMy WebLinkAbout0023 GENERAL PATTON DRIVE - Health 23 General Patton. Drive
Hyannis
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Commonwealth of Massachusetts 01?qa
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address *ex'
Paul Patalanot.
;
Owner
Owner's Name �
information is Hyannis MA 02601 10/9/2017 r!
required for every Y_
page. City/Town State Zip Code Date of Inspection
C>t:
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Paul Martin
use the return Name of Inspector
key.
Cape Cod Septic Services
Company Name
350 Main St
Company Address
W.Yarmouth MA 02673
Cltyrrown State Zip Code
508-775-2825 S15016
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the.inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/17/2017
I pector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of.completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of.inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
V8
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is required for every Hyannis MA 02601 10/9/2017
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System inn working condition.
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):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 17
r
'Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is required for every Hyannis MA 02601 10/9/2017
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is required for every Hyannis MA 02601 10/9/2017
-
page. Cityrrown 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 SASIs 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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
l5ins 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
•�" 23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is required for every Hyannis MA 02601 10/9/2017
—
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 D.EP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I.have determined that one or more of the above failure
criteria exist as described in 310°CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ' ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
r
Commonwealth of Massachusetts
AMMEMW Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
r 23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is required for every Hyannis MA 02601 10/9/2017
_
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facilityor dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of breakout?
® ❑ 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.
❑ z Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms.(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x3
330gpd
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 6 of 17
r
Commonwealth of Massachusetts
W r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is required for every Hyannis MA 02601 10/9/2017
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
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)): 2015=43gpd
2016=121gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: UnknownDate
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a "s Subsurface Sewage Disposal System Form-Not for Voluntary-Assessments
r 23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is required for every Hyannis MA 02601 10/9/2017
page. City/Town 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: No Records
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
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the.current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is Hyannis MA 02601 10/9/2017
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1979 Per BOH records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 30"feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
+10'
Distance from private waterRsupply well or suction line: feet
Comments(on condition of joints, venting, evidence of-leakage, etc.):
Line was checked with sewer camera and was found to be clean, properly pitched with no sign of root
intrusion.
Septic Tank(locate on site" Ian):
Depth below grade: 23"feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ -Yes ❑ No
Dimensions:
1000Gal
Sludge depth: 8-101,
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information required for':very is very Hyannis MA 02601 10/9/2017
page. Cityrrown 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
Scum thickness 6-7"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Estimated
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000Gal tank in good strucural condition. PVC Tees in place. Tank at normal operating level. Covers
6" below grade. Recommend service of tank.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
P
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•3113 Title 6 Official Inspection Farm:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•` 23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is required for every Hyannis MA 02601 10/9/2'017
-
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as 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 grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of'alarm and float switches, etc.):
"Attach copy of current pumping contract(required).Is copy attached? ❑ Yes ❑ No
t5ins•3113 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
.°r 23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is required for every Hyannis MA 02601 10/9/2017
page. Cityrrown 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
Oil
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box,etc.):
H-10 DB-3 with 1 line in and 1 line out in good condition. Box replaced in 2014. Box is clean and solid
with minimal solids carryover. No sign of overloading or hydraulic failure. Cover 6" below grade.
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: ,
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
I
Commonwealth of Massachusetts
Tithe 5 Official inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments
23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is required for every Hyannis MA 02601 10/9/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-6x6
❑ 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.):
1-6x6 Leach pit with stone. 1'of-effluent.in pit at time of inspection. No stain above 2'. No sign of
overloading or hydraulic failure. Cover 6" below grade.
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"t 23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is required for every Hyannis MA 02601 10/9/2017
page. Citylrown 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.):
b
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposa[System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is required for every Hyannis MA 02601 10/9/2017
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
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"t 23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is H annis MA 02601 10/9/2017
required for every y
page. Cityrrown State Zip Code Date of Inspection .
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
Shallow wells
Estimated depth to high ground water: +15
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:
Prior report hand auger to 14'with no water encountered.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of'Massachusetts
W u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Paul Patalano
Owner Owner's Name
information is required for every Hyannis MA 02601 10/9/2017
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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LOCATION SEWAGE PERMIT NO.
VILLAGE
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I N S T A LLER'S NA E i ADDRESS
R LU K 0 E R OR OWNER O
In
DATE PERMIT ISSUED
OAT E COMPLIANCE ISSUED
5
- j
http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=292130&seq=1 10/4/20 0
Town of Barnstable Barnstable
Regulatory Services Department
i MASS&UtNSTABM Public Health Division
0.59. 1�.
200 Main Street, Hyannis MA 02601 200�
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL #7012 1010 0000 2851 4044
November 5, 2014
Mary Ellen Alwardt Tr
c/o E. & S McIntyre TRS
25 Alwardt Way
East Falmouth, MA 02536
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5.
• The septic system located at 23 General Patton Drive, Hyannis, MA was last
inspected on 10/13/2014, by Paul Martin,. a certified -septic inspector for the
State of Massachusetts.
The inspection of the septic system showed that the system "Conditionally
Passes" under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) Due to the
following:
• Distribution box must be replaced.
• The tee on the septic tank outlet pipe must be replaced
You are ordered to repair or replace the septic system within sixty (60) days
from the date you receive this notification.
Failure to repair/replace the septic system with the deadline period will result in
future enforcement action.
PER ORDER OF THE BOARD OF HEALTH
f
• �McK
an, R.S. CHO
Agent of the Board of Health
Q:\SEPTIC\Conditionally Passes Ltr\23 General Patton Dr Hy Nov 2014.doc
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Parcel 292130 Developer LOT 36 >'
ID Lot
Location 123 GENERAL PATTON DRIVE I Frantapge 85
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Road Index 10595
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Owner JALWARDT,MARY ELLEN TR& I Co-Owner KINIYRE,E L JR&S Po9 TRS I IN
Street125ALWARDTWAY I Street2
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Computer name : HEALTH899JF User name : flvnni Operatinq Svstem : Windows NT(5.1)
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owner's Name
information is Hyannis MA 02601 10/13/2014
required for every -
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on.this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms V12q
I
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Paul Martin
use the return Name of Inspector
key.
Neighborhood Waste Water
Company Name
350 Main St
Company Address
r W.Yarmouth MA 02673
Cityrrown State Zip Code
508-775-2820 S15016
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 16.000).The system:
Passes Conditional) Passes ❑ Fails
❑ ® Y
❑ Needs Further Evaluation by the Local Approving Authority
10/14/2014
Inspector's Signature Date
.The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
}� of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
F 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.
� olZ � I
t5ins•3/13 Title 5 Official Inspection Fonn:Subsu Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owner's Name
information is Hyannis MA 02601 10/13/2014
required for every y
page. Cityrrown 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.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
>•'"� 23 General Patton Dr.
Property Address
Mary Ellen McIntyre _
Owner Owners Name
information is required for every Hyannis MA 02601 10/13/2014
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
® Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
® distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below):
D-box is rotted and needs to be replaced. Also no sanitary tee in place on outlet pipe. All covers
except for inlet of septic tank should be raised to be in compliance.
❑ 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
t5ins•3113 - Tale 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owners Name
information is Hyannis MA 02601 10/13/2014
required for every
page. Cityrrown 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
El ® 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 Y2 day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
51
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owner's Name
information is Hyannis MA 02601 10/13/2014
required for every y
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 16,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
AM i FM
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-- 23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owners Name
information is Hyannis MA 02601 10/13/2014
required for every
page. Cityrrown .State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined?(If they were not
® El available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): N/A Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): N/A
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
- f 23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owner's Name
information is Hyannis MA 02601 10/13/2014
required for every y
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 2012=115gpd
g ( Y g (gP )) 2013=113gpd
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No_
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 Fonn: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
__ 23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owner's Name
information is H annis MA 02601 10/13/2014
required for every y
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: No Records
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
❑ Privy
❑ . Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
v;1r@
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owner's Name
information is H annis MA 02601 10/13/2014
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information.(cont.)
Approximate age of all components, date installed (if known)and source of information:
Est 30 years
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan): -
30"
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: +10,
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Line inspected with sewer camera and was found to be clean, properly pitched with no sign of root
intrusion.
Septic Tank(locate on site plan):
Depth below gr.ade: 23"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of.Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000Gal H-10
Sludge depth: 81
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owner's Name
information is required for every Hyannis MA 02601 10/13/2014
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
27"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Sludge Judge/Tape
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1000 Gal H-10 tank in good overall condition. PVC tee in place and clean on inlet but no tee in place
on outlet. Inlet has risor and is 5"deep. No risor on outlet. Tank at normal operating level.
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.3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
"WESEM Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owner's Name
information is Hyannis MA 02601 10/13/2014
required for 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 grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:.
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"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
23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owner's Name
information is required for every H annis MA 02601 10/13/2014
y
page. Cityrrown 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.):
H-10 DB-3 with 1 line in and 1 line out in poor condition and walls are gone. Box needs to be
replaced
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:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owner's Name
information is Hyannis MA 02601 10/13/2014
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1-6x6
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
1-6x6 Leach pit exists on this system. 15"of standing liquid in pit at time of inspection with no sign of
overloading or hydraulic failure. Recommend installing risor on pit as cover is 40"deep.
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
^� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owner's Name
information is required for every Hyannis MA 02601 10/13/2014
page. Cityrrown 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
23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owner's Name
information is MA 02601 10/13/2014
required for every Hyannis
page. Cityrrown 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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owner's Name
information is required for every Hyannis MA 02601 10/13/2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: +14'
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)
lain:❑
Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Hand auger near pit to 14'with no groundwater encountered. Bottom of pit at 9'6". Minimum of 4'6'
groundwater separation.
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
23 General Patton Dr.
Property Address
Mary Ellen McIntyre
Owner Owner's Name
information is required for every Hyannis MA 02601 10/13/2014
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
No. �3 Fee 6d
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:s�
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
4plitatlon for Disposal *pstrm ConstCUttlon Permit
Application for a Permit to Construct( ) Repair((/Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. a_;; 6:e o e-4rl am? Owner's Name,Address,and Tel.No. CY rvv
✓yci.sty�e /=e.�r./y 7r�fsT
Assessor's Map/Parcel a. Z— U ''t
Installer's)la Addresse�d Tel.No r?v' rH Designer's Name,Address,and Tel.No.
.�ti•f Orf O d
a b!l��qr•7 S7: Ei/. ��urcG�s o�'6r
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs orAlterations(Answer when applicable)�,/¢Ie_.
�e 1 a�.tfa/y I'FiJyoj o f ti 4 orc�/cf a eel"'
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Si ice="���— Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued
No. i "'V 3 Fee /GU
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer L
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
application for Disposal *pstrm Construction Permit
' Applicat`>'l for a Permit to Construct( ) Repair(,//Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. ;7,3 Owner's Name,Address,and Tel.No. XWa_ri 7,+/o
C i.v tyiG /�a�ii y 7rv:-�T
Assessor's Map/Parcel a z—( U /'✓hr J �K3 ,�/wcrrc�f v� G o��> ,! o,TS—
Installer's Name,Address, nd Tel.No,/ Designer's Name,Address,and Tel.No.
k
Type of Building:
Dwelling—No.ofBedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
k.
Plan Date )Number of sheets Revision Date
��Title
'Si,e-,of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable),ef /
7.';9
` Date last inspected:
Agreement:
i, The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the prow§ions-of Title 5 of the EnvironmentallCode and not to place-the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Sig d Date
Application Approved by f Date
Application Disapproved by Date
for the following reasons
t
Permit No. /�/_ `i Date Issued
{ TICE COMMONWEALTH OF MASSACHUSETTS
S BARNSTABLE, MASSACHUSETTS
U r CPrtifirate of Compliahre
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired ) Upgraded( _)
Abandoned( )by ,C�� uw
at has been constructed in Uaccordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. u I l— !)3 dated ► I �!
InstallerG,.r �.� .� ��� �—�—` Designer
#bedrooms J� , Approved design flow f v 1 A-- rgpd
The issuance of this permit shall not a construe as
a '-uarantee that the system will function as designed./
Date P ` j Ins
P
/ V t
No. 1 ' Fee /(k)—
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction 3permit
Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( )
System located at 3 s„�aP/ y/�o�f,�•� 17r/.
h. and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date 1 �/C Approved by ��
7
LOCATION SEWAGE PERMIT NO•
VILLAGE
a
I N S T A LLE13'S NA E & ADDRESS
® UILDE R OR OWNER
C�
DATE PERMIT ISSUED
OAT E COMPLIANCE ISSUED
j
.' \cA
F
THE COMMONWEALTH OF MASSACHUSETTS
BOARD• OF HEALTH
................... . Town.....OF...Barnstable
Appliratioo for Bispooa1 Works Tooitrurtion ami#
Application is hereby made for a Permit to Construct ( ) or Repair (x) an Individual Sewage Disposal
System at:
_3.. General Patton Drive. .Hyannis _
---_...._........ ......... ..................................................................................................
Location-Address r Lot
Dorothv_-MacIntyre.............. ...__ 23 General Paton 'rive_, _Hyannis
W A & B Cesspool Service 128 Bishops TerPgrd%, Hyannis
a ----... ........
Installer Address
QType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................3..........................Expansion Attic ( ) Garbage Grinder ( )
`4 Other—T e of Building No. of persons.............2............. Showers — Cafeteria
Q' Other fixtures ------------------------ •---------------------------------------------------------------------------
--------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow.._..._..................................•._gallons.
WSeptic 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........................................
W
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes-per inch Depth of Test Pit.................... Depth to ground water........................
............................
-................................................................................................................................
0 Description of Soil...............Sand------.......-•------------------------------------••------•-•-•--•-•--•-•-----•---•---•-•-•---------
x
W •------•-•-•---------------------••-•••-••--•••-•••••--•-•-•-------••---•--(-replar-ing---old---metal...sep-tic...tank)------------------------------
VNature of Repairs or Alterations—Answer when applicablelns calla.t.i.on...of__-a...cample.te.__new.......
14.0.Q---gallon...saptic...tank.,.•--i...d-ts-t-ri.bution...box...an-d....(l)
Agreement: 11,000 gallon stone packed leach pit (overflow)
' The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TI IT,1L 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issuej&the boar i th.
Signed- • ... y-c s� •----- ...4'7�li
Date
Application Approved By. "x
.•--.--
Date
Application Disapproved for the following reasons:..............................................................................................................-
....---•-----------------------------------------------•--....--•••-------------.............----------...-••-•••-=--••------------•-••-----•-----•------•--•----•---•-•--••-••••----••...••-•-•...--•---
e
Permit No....79----------3-�-�---------------------- Issued.......�............................................
Date
No 79 Fim .00M
THE COMMONWEALTH OF MASSACHUSETTS
s. BOARD OF HEALTH
...... ... .....................'it .OF...� '11.� ���. ..........................•---..........................
k Iirttti�an for 11b VasFal larks` Tonstraretiun pranit
A P~licatiori`is hereby made for a Permit to Construct or Repair ( ) an Individual Sewa a Disposal
Systeni-it:
--•-•-------------------------------------- ... .........-
23. --- - __
Location-Address
Q ®° ' M x r ........:.... 23 General Patf ont ti4e, HyBe is
... ....------------- ---------• ............
A.. Des spool Service-....:............... 128 Bishops Te krdA, ya�nA.r
-
Installer
Address
Type of_Building Size Lot...................-------.Sq. feet
�-, Dwelling—No. of Bedrooms................`�V--------------............Expansion Attic ( ) Garbage Grinder ( )
Other='T -e of Building No. of persons...._..._..•.0............. Showers ( ) — Cafeteria ( )
Otherfixtures -------------------------------------------------------••••••••-•••-••--••••••••-•••••-•-•=•••••-••-•...--•--•••--•-••...._
.............................
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic'Tank—Liquid capacity............gall`ons Length................ Width................ Diameter................ Depth.................
x Disposal Trench—.No..................... Width..`...................Total Length.___---__._:__.--:-_ Total leaching area---------:_.........sq. ft.
Seepage Pit No------------------- Diameter.................... DeptlVbelow inlet.................... Total leaching area........_.........sq. ft.
Z Other Distribution box ( ) Dosing tank
aPercolation Test Results Performed,by..........................................................................,. Date........................................
Test Pit No. l................minutes per inch Depth Hof Test Pit ................ Depth to'ground water........................
44 Test Pit.No. 2................minutes per inch. - Depth'of Test Pit.................... Depth to ground'water_:. ...................
-----------------•-----...----.....------._......----........--•--.......--•-••----------------.._•.. .........................
ODescription of Soil........ r'9 + ...........................................................................................
x
U ............ -------•-------=-----•---=••••-••-•.....•••••.............•-•-•---•••-----....-•----:..:.............-_----••...•-••••--•--••...:...-----------.........:•.: = -----------•--••-
UNature of Repairs or Alterations—Answer when applicable..TVatEL1�.-' �. �..•;nf.._a...aampla$461'-, _nSw-------
Agreement: 14000 ' gallon Stonie paoked ,leach pit (overflow)
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the ions of TTLL
p 5 of the State Sanitary Code=The undersigned.further agrees not to place the..system in
operation until a Certificate of Compliance has �issue'
the boar h. /.
Signed `a ...`'
Date
ApplicationApproved By....... --•-----------------------• •--------------------------..........---- -- ..................................'
a Date
APPlication'Disapproved for the following reasons:----•------- --------.....................................'......................
_
--......--•-----------------------------------•-----------.._...---•--------------.---•---•------.....---••••-•-•...-----•--•---••---•-••••--•••-••••••••••------=•-•_•-•---•--•............-•••-•-----
3 � .
.Permit'No.......�:'------- ----------------------------------- Issued..........................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
1.
BOARD' OF 'HEALTH .
.............. ;T ..OF...ft. .0t 3 1 @....:............................................
f�rrtifirtt�e oaf ��ant�ii�anrr .
THIS IS TO CERIFY, Th t the Ir�u v ual Se age Disposal System onstruc.tO ( � or j j (X )
by A__&:-B..Cesspool erce, 3 Ois ape Xarrace, yannis# h a.
.} Q ,..... -}-�♦----•--• ••--nos-- . Dorothy
® ...�p t - --- -------- ---------
at j..Agne_3.6 l Pa Z t on D i V b l-- i+�yar 6i�i'$3tal-� ;t�'tid''ro by Macc Intyr
----__• --••-••-•-•-•••••---••••......--••- ..............•-••--•••-
has been.installed in accordance with the provisions of TI`l'Iy j of The State Sanitary Code as described in the.__
application for Disposal Works Construction Permit No 7.ty :.......................... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..... �--`•-��•-----•--•---•-----------------•------______. Inspector.... .:_ ®r, `c ..............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOVM .,OF...........Ba. . t.ab ee
................................... $J a 00
No... 9-• �.. 7 FEE.............:.
Disposal World TrEonstrnrtion rranit
Permission is hereby granted.. ..&_.B._cesspool..ser ...............................................................io "' ' shopsTer c , Kyann18
. ..,..
to Construct or tr an n vldual evc�a a is osal S st
at No...__��..j..Uene � p a� on r`�.•ve, fWaip --y ToTothy MacIntyre
-------------••• ••-•-••• ...-_.-- ----•-•• •---------•--••-••.---------
Street 7 Q—
as shown on the application for Disposal Works Construction Permit No�'............... Dated...... ...':LI"--.f.._.•------.•
_.......................... I-•---••...........),:•-•---......_
Board of Health
DATE................................................................................ L
FORM. 1255 HOBBS & WARREN, INC., PUBLISHERS