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Separation Distance Between the:
` Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) , Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) ' Feet
FURNISHED BY >
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'cam Commonwealth of Massachusetts 0290? —
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 General Patton Dr
Property Address �,ro
Uillian DaSilva �:
Owner Owner's Name/
information is Hy annis ✓ MA 02601 09/30/2020
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
filling out forms A. Inspector Information /4{ ��{ 9C-O
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
52 Rivers End Road
� Company Address
Teaticket Ma. 02536
Cityjown State Zip Code
508-280-3356 S13938
Telephone Number, License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i
,., 32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is required for every Hyannis MA 02601 09/30/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This 3 bedroom home has a 1500 septic tank with an H-10 D-Box feeding infiltrators'uiith stone. At
the-time of the inspection no visible failure criteria was found.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y -❑ N ❑ ND (Explain below):
I
i
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
i .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is Hyannis MA 02601 09/30/2020
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
I
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
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):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
r
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is required for every Hyannis MA 02601 09/30/2020
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
"*This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑' ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is required for every Hyannis MA 02601 09/30/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with'a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ . the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA)or a mapped Zone II of a public water supply well
l5insp.doc•rev.7/26/2018 Z Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Flo Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments
u
32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is required for every Hyannis MA 02601 09/30/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
.t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is required for every Hyannis MA 02601 09/30/2020
page. Citylrown State Zip Code Date of Inspection
D. System Information
1. 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): 330 plus
GPD
Description:
Number of current residents: 5
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage town water
9 ( Y 9 (gPd))�
Detail
i
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:-Subsurface Sewage Disposal System•Page 7 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is required for every Hyannis MA 02601 09/30/2020
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial-waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
r
Commonwealth of Massachusetts
�^ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c, 32 General Patton Dr
u—
Property Address
Uillian DaSilva
Owner Owner's Name
information is required for every Hyannis MA 02601 09/30/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type'of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) .
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No,
5. Building Sewer(locate on site plan):
Depth below grade: 24"
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Water was flushed and came freely.
I
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is required for every Hyannis MA 02601 09/30/2020
-
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
. "
Depth below grade: 16
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: 1500 gallon
Sludge depth:
2"
Distance from top of sludge to bottom of outlet tee or baffle
3411
Scum thickness
Distance from top of scum to top of outlet tee or baffle
13"
Distance from bottom of scum to bottom of outlet tee or baffle
sludge judge
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the liquid level was at working level
and the tee's were in place.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
i
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is required for every Hyannis MA 02601 09/30/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.•, 32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is Hyannis MA 02601 09/30/2020
required for every y
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
0„
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage or solids carryover.
t5insp.doc•rev.7/26/20111 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
I
c .� Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is required for every Hyannis annis MA 02601 09/30/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
i
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is required for every Hyannis MA 02601 09/30/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At the time of the inspection no visible failure criteria was found.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil,.signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
t5insp.doc-rev.7126120118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
j
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is required for every Hyannis MA 02601 09/30/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
32 General Patton Dr
Property Address
Uillian DaSilva
Owner owner's Name
information is required for every Hyannis MA 02601 09/30/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
Drive
A B
Q ( A B
1 24' 21'6"
a 2 18' 27'3"
3 29' 49'
t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Ala Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is required for every Hyannis MA 02601 09/30/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
i
® Check cellar
® Shallow wells
Estimated depth to high ground water: 10 plus feet
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: .
I augered a hole at a lower elevation and shot it with a transit.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.......... •, 32 General Patton Dr
Property Address
Uillian DaSilva
Owner Owner's Name
information is required for every Hyannis MA 02601 09/30/2020
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
I
15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
COMMONWEALTH OF MASSACHUSETTS
f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
o DEPARTMENT OF ENVIRONMENTAL PROTECTION
,
S�ev`0
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION C7_//C7_
Property Address: 32 General Patton Drive
Hyannis MA 02601
Owner's Name: Madlon Jenkins
Owner's Address: 29 Cobblestone Way
East Sandwich MA 02537
Date of Inspection: August 14,2006 Job#06-217
Name of Inspector: PATRICK M. O'CONNELL
Company Name: SEPTIC INSPECTION SERVICES CO.
Mailing Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telephone Number: 508-428-1779
CERTIFICATION STATEMENT
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: t9.1XV Uq//�
X Passes
!Conditionally Passes O
Needs Further Evaluad by the Local Approving Authority �: PAT "K i
— F 'C NEL c,
Inspector's Signature: Date: 8/14/06 `�
F5/NS
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of He tanttt%0\
DEP)within 30 days of completing this inspection. I I'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.
Notes and Comments: Leaching system has no standing water or evidence of surcharge.Tank is not in need
of pumping at this time.
tn:r�14
t;11n t��
J
****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. :,j
Page 2 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 32 General Patton Drive, Hyannis
Owner: Madlon Jenkins
Date of Inspection: August 14,2006
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ 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.
Answer yes,no or not determined (Y.N,ND) in the_ 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 ifthe
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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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
ohsh•uctiun is removed
ND explain:
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 32 General Patton Drive, Hyannis
Owner: Madlon Jenkins
Date of Inspection: August 14,2006
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
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
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 aseptic 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen 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:
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 32 General Patton Drive, Hyannis
Owner: Madlon Jenkins
Date of Inspection: August 14,2006
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no" to each of the following for all inspections:
Yes No
_X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
—X— Discharge or pending of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
—X— Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_X Liquid depth in cesspool is less than 6" below invert or available volume is less than_day flow
—X— Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS, cesspool or privy is below high ground water elevation.
—X— Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
_X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
—X— 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 coliform bacteria.and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen 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 forma
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CM 15.303, therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
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.
You must indicate either"yes" or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 leet 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
Ifyou have answered"yes" to any question in Section 1=. 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.
Page 5 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 32 General Patton Drive, Hyannis
Owner: Madlon Jenkins
Date of Inspection: August 14,2006
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
_X_ _ Pumping information was provided by the owner,occupant,or Board of Health
_X_ Were any of the system components pumped out in the previous two weeks'?
_X_ Has the system received normal flows in the previous two week period ?
_X_ Have large vole nes of water been introduced to the system recently or as part of this inspection?
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ _ Was the facility or dwellino inspected for signs of sewage back up
_X_ _ Was the site inspected f-or signs ol'break Out
_X_ _ Were all system components,excluding the SAS, located on site
_X _ 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?
_X _ 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:
Yes no
_X_ _ Existing information. For example, a plan at the Board of Health.
X _ Determined in the lield (if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable) [310 CINIR 15.302(3)(1))J
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I '
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 32 General Patton Drive, Hyannis
Owner: Madlon Jenkins
Date of Inspection: August 14, 2006
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Ntnnher of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms):330
Number of current residents: 0
Does residence have a garbage arincler(yes or no): No
Is laundry on a separate sewage system (yes or no): No (if yes separate inspection required]
Laundry system inspected (yes or no):
Seasonal use: (yes or no): No
Water meter readings. if available(last 2 years usage(gpd)): Two years total: 131,250 gal.= 179 gpd.
Sump pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CM 15.203): _____^_____gpd
Basis of design flow(seats/persons/sgft.etc.): `
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no): _
Non-sanitary waste discharged to the Title 5 system (yes or no):
Water meter readings, if available:
Last date of occupancy/use: _
OTHER(describe):
GENERAL INFORMATION
Pumping Records: None
Source of information:
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons -- How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
_X_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 ol'the Dlp approval
Other(describe):
Approximate age ol'all components. date installed(il'known)and source of information:
Compliance date: 3/13/90
Were sewage oclors detected when arrivino.at the site(yes or no): No
r
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE, SEWAGE DISI'OSAL SYSTEM INSPECTION FORM
PART C
t SYSTEM INFORMATION (continued)
Property Address: 32 General Patton Drive, Hvannis
Owner: Madlon Jenkins
Date of Inspection: August 14, 2006
BUILDING SEWER: XX (locate on site plan)
Depth below grade: I'
Materials of construction: _X__cast iron __40 PVC__other(explain):
Distance from private water supply well or suction line:
Comments(on condition ofjoints, venting, evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: I'
Material of construction: --X_—concrete--_metal `fiberglass_polyethylene
_other(explain)__
[f tank is metal list age:— Is a-e confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 10.5' long x 5.8' wide— 1500 gal.
Sludge depth: 2"
Distance from top of sludoe to bottom of outlet tee or baffle:30"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of SCUM to bottom of outlet tee or baffle: 12"
How were dimensions determined: STICK WITH HINGE FLAP.
Comments(on pumping recommen(lations. inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees are intact and clear, liquid level is at bottom of outlet invert and tank is not in need of pumping
at this time.
GREASE TRAP: No (locate on site plan)
Depth below gracle: _
Material of construction:_ concrete__metal fiberglass_polyethylene_other
(explain): -- ------- ------ --
Dimensions:
Scum thickness: _
Distance from tip 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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
r -
Page 8 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 General Patton Drive, Hyannis
Owner: Madlon Jenkins
Date of Inspection: August 14, 2006
TIGHT or HOLDING TANK: No (tanl< must be pumped at time of inspection) (locate on site plan)
Depth below grade:_
Material of construction:I_ concrete __metal .---fiberglass polyethylene other(explain):
Dimensions:---------
Capacity: — — _— "allons
Design Flow:
Alarm present(yes or no): —
Alarm level: Alarm in working order(yes or no):
Date of last pumping: !^
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: XX (il'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.):
Observed a trace of solids in corners of box. No high stains or evidence of backup were present.
Liquid level is equally balanced between both outlet pipes.
PUMPCHAM13I R: No (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition 0I'pump chamber. condition of pumps and appurtenances,etc.):
I
f
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OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SLIBSIJRFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 32 General Patton Drive, Hyannis
Owner: Madlon .lenkins
Date of Inspection: August I4,2006
SOIL ABSORPTION SYSTEM (SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
_leachin,pits. number:
_X_leaching chambers, number: R Infiltrators
_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, sins of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.): Interior of SAS was video inspected and no standing water or evidence of surcharge was observed.
CESSPOOLS: No (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 laver:
Depth of scum laver:
Dimensions of cesspool:
Materials of construction:
Indication ofgroundwater inllow(yes or no):
Comments(note condition of soil. signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: No (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition ol'soil. signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Page 10 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 32 General Patton Drive, Hyannis
Owner: Madlon Jenkins
Date of Inspection: August 14, 2006
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch ofthe 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.
General Patton Dr.
..............
2
17
27
Page I 1 of 1 I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE., SFWACE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 Cencral Patton Drive, Hyannis
Owner: Madlon Jenkins
Date of Inspection: August 14, 2006
SITE EXAM
Slope None
Surface water None
Check cellar 1)ry
Shallow wells None
Estimated depth 10 �rc�un �w d atcr : More than 15 feet
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(abuttin(I property/observation hole within 150 feet of SAS)
_Checked with Ideal Board of Health-explain:
_Checked with local excavators. installers- (attach documentation)
_X_Accessed USGS database-explain: USCS topo map and town CIS
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water below el. 25 and topo map shows property above el.40.
� - COMMONWEALTH OF MASSACHUSETTS
a
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
b DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP
PARCEL
LOT
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 32 General Patton Drive
Hyannis MA 02601 RECEIVED
Owneir's Name: Courtney Jenkins
Owner's Address: Same
FEB 2 5 2004
Date o l'Inspection: February 6,2004
TOWN OF BARNSTABLE
Name(if Inspector: PATRICK M.O'CONNELL HEALTH DEPT.
Company Name: SEPTIC INSPECTION SERVICES CO.
MailinI;Address: 189 CAMMETT ROAD
MARSTONS MILLS MA 02648
Telepfi-)ne Number: 508428-1779
CERTIFICATION STATEMENT
I certif)-that I have personally inspected the sewage disposal system at this address and that the information reported
below i;true,accurate and complete as of the time of the inspection.The inspection was performed based on my
traininj! 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: ``'0%%J11u►1111
PP Y P P ( ) Y ���H OF
_X_ Passes 2 : .�y'10 P
Conditionally Passes ;�; TRI N
Needs Further Evaluation by the Local Approving Authority = M. 'm
Fails 0'
Inspei,tor's Signature: _ Date:
INSPE������
The sy,,tern inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or.
DEP)v-ithin 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or,;neater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. T he original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authorh y.
Notes and Comments: System in good condition.Observed trace of scum in d-box, recommend effluent filter.
****TI is 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
conditi ins of use.
Title 5 .nspection Form 6/15/2000 page 1
Page 2 A 11
13FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 32 General Patton Drive,Hyannis
Owner: Courtney Jenkins
Date cif Inspection: February 6,2004
Inspeo ion Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
_XX_ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.302 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.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined"please
explair.
"he septic tank is metal and over 20 years old*or the septic tank(whether met31 or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existini:,tank is replaced with a complying septic tank as approved by the Board of Health.
*A mei it septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicat:ng that the tank is less than 20 years old is available.
ND exp lain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstruc:ed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approv.it of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND exF lain:
The system required pumping more than 4 times a year due to broken or obstnicted pipe(s). The system will .
pass im,pection if(with approval of the Board of Health).-
broken pipe(s)are replaced
obstruction is removed
ND ex f fain:
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OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:32 General Patton Drive, Hyannis
Owner, Courtney Jenkins
Date ol'Inspection: February 6,2004
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
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 colifonn
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen 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:
a
Page 4 A I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 32 General Patton Drive,Hyannis
Owner: Courtney Jenkins
Date of Inspection: February 6,2004
D. System Failure Criteria applicable to all systems:-
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
j _ X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ _.X— Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
X_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than %Z day flow
X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X_ Any portion of the SAS, cesspool or privy is below high ground water elevation.
X_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_X_ Any portion of a cesspool or privy is within a Zone l of a public well.
X_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X_ 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. IThis system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen 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.l
No_.(Yes/No)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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 h ive answered"yes"to any question in Section E the system is considered a significant threat, or answered
"yes"hi 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.
A
Page ff 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 32 General Patton Drive,Hyannis
Owner: Courtney Jenkins
Date of inspection: February 6,2004
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?
_X_ _ Has the system received normal flows in the previous two week period`'
_X_ Have large volumes of water been introduced to the system recently or as part of this inspection
_X_ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
_X_ Was the facility or dwelling inspected for signs of sewage back up-?
_X_ ___ Was the site inspected for signs of break out?
_X_ ___ Were all system components,excluding the SAS, located on site?
_X_ _ 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?
_X _ Was the facility owner(and occupants if different from owner)provided with information on the proper
mainte-lance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes uo
_X_ __ Existing information.For example, a plan at the Board of Health.
X_ _ Determined in the field(if any of the failure criteria related to Part Cis at issue approximation of
distanc:is unacceptable) [310 CMR 15.302(3)(b)]
Page ti of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:32 General Patton Drive,Hyannis
Owner: Courtney Jenkins
Date of Inspection: February 6,2004
FLOW CONDITIONS
RESIDENTIAL
Numb:•of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIG V flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Numb:•of current residents:5
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laund-/system inspected(yes or no):
Seasonal use: (yes or no): No
Water rneter readings,if available(last 2 years usage(gpd)): Two years usage: 68,475 gal.=93 gpd.
Sump pump(yes or no): No
Last d:r:e of occupancy: Currently Occupied
COMMERCIALANDUSTRIAL
Type o'establishment:
Desigr flow(based on 310 CMR 15.203): U
Basis(if design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sEtnitary waste discharged to the Title 5 system(yes or no):_
Water rneter readings,if available:
Last dire of occupancy/use:
OTHE R(describe):
GENERAL INFORMATION
Pumping Records: None
Source of information: -
Was s):,tem pumped as part of the inspection(yes or no): No
If yes, volume pumped:_gallons--How was quantity pumped determined?
Reasor for pumping:
TYPE,OF SYSTEM
_X Se ptic tank,distribution box,soil absorption system
_Single cesspool
_ON-rflow cesspool
_Pri vy
—Sh►red 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
obtaine i from system owner)
-Til ht tank _Attach a copy of the DEP approval
_Otl ier(describe):
Approximate age of all components,date installed(if known)and source of information:
Compliance date:3/12/96
Were sewage odors detected when arriving at the site(yes or no): No
r.
Page" if I i
13FFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 General Patton Drive,Hyannis
Owner: Courtney Jenkins
Date 0*Inspection: February 6,2004
BUILID-ING SEWER: X (locate on site plan)
Depth below grade: Under slab
Materials of construction:—X—cast iron _40 PVC_other(explain):
Distan ze from private water supply well or suction line: 25'
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTYC TANK: X (locate on site plan)
Depth below grade: I
Materi 31 of construction:—X—concrete_metal_fiberglass_polyethylene
_othar(explain)
If tank s metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions: 10.5' long x 5.8'wide—1500 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:30"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 13"
How w ere dimensions determined: STICK WITH HINGE FLAP.
Comm.:nts(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as relat;;d to outlet invert,evidence of leakage,etc.):
Tees intact and clear.Tank not in need of numaing.
GREA4E TRAP: No (locate on site plan)
Depth 1,elow grade:_
Mated,1 of construction:_concrete_metal_fiberglass_polyethylene_other
(explab i):
Dimenf ions:
Scum tlickness:
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:
Commt nts(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as relawd to outlet invert,evidence of leakage,etc.):
Page 1; if I t
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 General Patton Drive,Hyannis
Owner: Courtney Jenkins
Date cal'Inspection: February 6,2004
TIGHT'or HOLDING TANK: No (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
Desigr. Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date o f last pumping:
Comm:nts(condition of alarm.and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened) (locate on site plan)
Depth,A liquid level above outlet invert: 0"
Comm:nts(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.):
Box set level,flow equal to both outlets. Observed trace of carryover in b)ox,recommend effluent
filter ir:tank.
PUMP CHAMBER: No (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n
i
Page') A 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 General Patton Drive,Hyannis
Owner: Courtney Jenkins
Date of Inspection: February 6,2004
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
I!aching pits,number:
_X vaching chambers,number: 8 Infiltrators.
l.:achirig galleries,number:
l,:aching trenches,number, length:
l-:aching fields,number, dimensions:
overflow cesspool,number:
binovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil, condition of vegetation,
etc.): No excessive vegetation or evidence of ponding.
CESSPOOLS:No (cesspool must be pumped as part of inspection) (locate on site plan)
Numbe•and configuration:
Depth--top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimen.-ions of cesspool:
Materh Is of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVI: No (locate on site plan)
Materials of construction:
Dimew ions:
Depth of solids:
Comme nts(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Page .0 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 General Patton Drive,Hyannis
Owner: Courtney Jenkins
Date of Inspection: February 6,,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchir arks.Locate all wells within 100 feet. Locate where public water supply enters the building.
General Patton Drive
wI5
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ll pl�l
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Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 32 General Patton Drive,Hyannis
Owner: Courtney Jenkins
Date of Inspection: February 6,2004
SITE EXAM
Slope None
Surfact:water None
Check .:ellar Dry
Shallov,wells None
Estimai ed depth to ground water: More than 15 feet
Please ndicate(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 150 feet of SAS)
C iecked with local Board of Health-explain:
C iecked with local excavators,installers-(attach documentation)
_X_A ccessed USGS database-explain:USGS topo map and town GIS
You mi ist describe how you established the high ground water elevation:
Town groundwater contour map shows water below el.25 and topo map shows property above el.40.
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PROPOSED MODIFICATIONS MICHELE CUDILO, P.E.
Consulting Structural Engineer
Centerville, Massachusetts 02632-1979 (508)771-7601
Drawn By: MC Date: 07/23/15 Drawing.
32 GENERAL PATTON DR. sale: g'A� NOTED Rev. o
HYANNIS, MA S K— 3
File Nome:DASILVA Project No.2015-153
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Health Complaints
16-Jul-03
Time: 2:30:00 AM Date: 7/10/2003 Complaint Number: 4158
Referred To: DAVID STANTON Taken By: JOAN AGOSTINELLI
Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH
Article X Detail: UNSANITARY CONDITIONS
Business Name:
Number: 32 Street: GENERAL PATTON
Village: HYANNIS Assessors Map-Parcel:
Complaint Description: TRASH ALL OVER THE YARD.
Actions Taken/Results: DS WENT TO SAID LOCATION, NO ONE
WAS HOME. SPOKE WITH NEIGHBORS,
THEY SAID IT HAS BEEN CLEANED UP,
AND THE PEOPLE ARE USING BFI. THEY
SAID THE OTHERDAY THERE WAS A BAG
OUT THERE WITH FLIES, BUT HAS SINCE
BEEN REMOVED
Investigation Date: 7/16/2003 Investigation Time: 11:20:00 AM
1
Health Complaints
20-May-03
Time: 9:30:00 AM Date: 5/15/03 Complaint Number: 4033
Referred To: DAVID STANTON Taken By: KARYN DACE
Complaint Type: NUISANCE CONTROL REG. 1 RUBBISH
Article X Detail: UNSANITARY CONDITIONS
Business Name:
Number: 32 Street: General Patton Drive
Village: HYANNIS Assessors Map-Parcel:
Complaint Description: The neighbors at 32 G.P. Drive have an
overwhelming trash problem. Trash bins are in
the back yard behind a fence, but trash is
overflowing out of bins, is strewn around the
back yard. Building debris is also strewn
around yard. The situation is drawing flies and
the real heat has not yet set in; complainant is
deeply concerned and would like the matter
addressed. A complaint has been leveled in
the past(3/21/2000) against the residents at
this same address. Complainant states that the
residents have BFI services available and does
not know why they do not rectify the situation
themselves.
Actions Taken/Results: DS WENT TO SAID LOCATION. NO ONE
WAS HOME. DID NOT OBSERVE ANY
TRASH. ALL OF THE OTHER PROPERTIES
NEAR BY DID HAVE RUBBISH PRESENT.
DS WENT BACK TO PROPERTY
FOLLOWING MORNING AT 11:30 AM, NO
ONE WAS HOME, BFI WAS PRESENT THIS
TIME, REMOVING TRASH BIN FROM SAID
PROPERTY. NO ACTION IS REQUIRED AT
1
Health Complaints
20-May-03
THIS TIME, AS A VIOLATION HAS NOT
BEEN OBSERVED AT THIS LOCATION.
COULD NOT GET ACCESS TO BACK YARD.
COULD NOT SPEAK WITH COMPLAINANT,
AS IT WAS ANONYMOUS.
Investigation Date: 5/15/2003 Investigation Time: 2:30:00 PM
i •
2
r� TOWN OF BARNSTABLE
L&ATION 3Z G$YJ�i�`Q�' /� �1 dip SEWAGE#
V LAGE 6'Yj&015 //A--SSESSOR'S MAP &LOT
INSTALLER'S NAME&PHONE NO. AprtOG�/ GD6 �1/` 3yy
F SEPTIC TANK CAPACITY /Sy0
LEACHING FACILITY: (type) W��><�fir._S (size)
NO.OF BEDROOMS
Ai sods
BUILDER OR OWNER V0 /
PERMITDATE: Z —i —f COMPLIANCE DATE:
i
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility t Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) ''0 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Nlk Feet
Furnished by
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.No. � Fee G'Q
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for Mgooal bpotem Cone;truction 3permit
Application is hereby made for a Permit to Construct( )or Repair C>4—)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
t'$ /VIQ G_xz 6 I r\1" /V%A- Cif(i U
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
dY!�W» GYM i- GYZ I.O )� U1 ►1ST
-o .400,1_. Zug/
vin�,tis;o�..rs �++�i,t..S ✓v!4 G�3-t9 Y�
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow S� J,3O gallons per day. Calculated daily flow -33a gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) SO "sznL
T o �o /►.� F--7 c�/C.>9�/1_S W ,J IKA-AGE if— -3 U � p�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this and f Heal
Signed Date
Application Approved
Application Disapproved for the following reasons
Permit No. Date Issued
`.^
No. / Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION='TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for Migool *pgteml COttgtru tiOtt Permit
Application is hereby made for a Permit to Construct( )or Repair(x)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel No.
r,2.� ���-'%6 w I`•cam: �►� -ems m.�
/-� �,a "�;cS , �ytiq G�-G o► e
Installer's Name,Address;,and Tel.No. Designer's Name,Address and Tel.No.
0 X7_0 WI G_6 .N,i o/t—t �-7 C lJ ►,A
P-o '6G-A_ 7av
f} dlnA,4_�,o^JS ems, t l,tS ✓v14- 0.�L-6`f lS
I pe,of Building:
/ Dwelling No. of Bedrooms Garbage Grinder( )
Other Type of Building No. of Persons Sho ecs-(--) Cafeteria( )
Other Fixtures
Design Flow t Sr 3 3O gallons per day. Calculated daily flow 326 gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) N~ /4- 1 SO Ul ZYnZ- '7ii�vv1L
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the'Environmental Code and not to place the system in operation until a Certifi-
cate:of Compliance has been issued by this and f Heal
Signed_ - Date .�
Application Approved
Application Disapproved for the following reasons -
_
r Permit No. Date Issued
-_.---
-___---.-_- �t _--4-1-._.-
THE COMMONWEALT�OF MASSACHUSETTS 9Z ')4
PUBLIC HEALTH DIVISIONwBARNSTABLE, MASSACHUSETTS
Certificate Of Compliance
I
THIS IS TO CERTIFY,that the On-site Sewage Disposal System-iitstalled( )or repaired/replaced(`DC}on
by '761/M-V L4-1T1 Co ,J S7-lLv C77u.J for W i u(3 fhx� Q 4^JA%, J o.J
as �i457V AJ 0/C, Jt /q j 1v Iv I% has been constructed in acc rdance
with the provisions of Title 5 and the for Disposal System Construction Permit No. J dated
Use of this system is conditioned on compliance with the provisions set forth be ow:
-----No. 6 92 Fee /
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migo5al *pgtem Cow5truction Permit,
.Permission is hereby granted to U�'7 U,J
to construct( )repair .an On-site Sewage System located at JL)-- U-4- - n_A-"-7v'J
Q AA Jf t ty}r.l+mil LS`
and as described in the above Application for Disposal System.Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
\ �N
All construction must be completed within two years of the date below.
Date: r,�� �1� ApprovedS' '�
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at Q/i-Jt meets all of the
L-4, i-"jrj�S
following criteria:
I here are no wetlands Nrithin 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
Ie observed groundwater table is 14 feet or greater below the bottom of the leaching facility
There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
SIGNED:
DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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Y �d« .,y` f�' 'F'.d S.a 4.'4 �4'•..�Ck l.J+,�{�:f 7r�f .r`:j:'9.WR{•ty 3'xr .+��r,.r�c i��'`} ' r i�'Q'.�F��w�'_ 'Jtt� �,e �� •s q� T 4 �-:.t w�A L'-.
..4' ,, „,}„ .s. .�''1, '�' 4; .. .F.+`'- +{'a � Ltr"y > • ,M'..J��. � c ,*}''._�,HE.#'�+�
�.� � tK"• siK ,.� c •.
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�, sir
C*v
�`s�`mac-
Town of Barnstable
Department of Health, Safety, and Environmental Services
tt � Public Health Division
367 Main Street, Hyannis MA 02601
Office: 508-790-6265 Thomas A McKean
FAX: 508-775-3344 Director of Public Health
9/27/95
Dorothy Donaldson
8 Orrs Ave., P.O. Box 1917
Hyannis, MA 02601
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 32 General Patton Drive, Hyannis was
inspected on August 28, 1995 by Joseph Macomber a Massachusetts licensed septic
inspector. '
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility.
You are directed to hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 Main Street, Hyannis) that will bring the septic system into compliance
with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen
days of receipt of this notice. You are also directed to bring the septic system into
compliance within thirty (30) days of receipt of this order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
T
[Installer letter] Sl
TO: l,76 Qt?�i �isiY�I� .�a�tl (Date)
D x
/ ,4 sv,v -1?
ORDER TO COMPLY WITH 310 CMR .15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5. �
The septic system owned by you located at j�� 47'Z was
inspected on 'd "��by 'Qs�rsl� �l�l,�l��n1, ,a-Massachusetts licensed septic
inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00)due to the following:
i.f�— `
v
You are directed to hire a licensed Town of Barnstable septic system installer to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office
(Town Hall, 367 main Street, Hyannis) that will bring the septic system into compliance
with 310 CMR 15.00, The State Environmental Code, Title 5 within (14) fourteen days of
receipt of this notice.
You are also directed to bring the septic system into compliance within thirty (30) days of
receipt of this order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
P
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
DATE:�4/?8 Q: .;
.2 . .
PROPERTY . ADDRESS: _
74e.ue _ IVV
D u D 9. .. - WAL.TH MOT
r
_ �---- VO OF&AANSTABLE
On the above date, 1 Inspected the septic system at the above. address.
This system consists of the .following:
c"* ; oo2..
Based on my InRoection, I certify the following conditions:
1 . 7,hi,3 -..ins aat. a k.Zt,.P-e ,P �e,`..�ej�� c�'�sy•+�mf -� C"
a :aer�age• -�yhtesiit .t..h�.t 1-iiied to 1115- capac..ity.
i 3. 7hr^ .sewa e.s�-�#.em . i s i.n ;eaie_ria.e.
4 1,%.zt.: Lee. u,Qga.aded .to _�, t.it.2��-�,�vn '�e.�t.i r. •sy���m..:.�..:;;
SIGNATUR',:
Flame: J_P.M_acomber Jr;..
:
J•P_Macomber• &. -Son- 'Inc.
Company • ' ,
_-._------ --
Add•ress:__B4,,,_b4,-----= ---,--
Centerville LMass__0.2.632
1 Phone:---SQ8�.7.5•�3338____--- •., 1 . .
THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY
JOSEPH P. MACOMBER & SON,. INC.
Tanks-Ceupools-Leachfields
+ Pumped & InsUlled
Town Sewer Connections
P.O. Box 66' Centerville, MA 02632-0066
77.5.3338 775-6412
VE ACE DISPOSAL SYSTEM I2;L'^^
AONress Of. Proper.tj, .32 91iAeaai Patton Daive'_ Kya,znin, �la�e.
Owner's name Doaethy Dona dsoR
Date of Inspection 8128195
PART A a
CliUCKLIST
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of.
Health. j
1
None of the system components have been pumped for at, least two weeks
and the system has been receiving normal flow rates during that , r '
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are- not '
available with N/A.
,ZThe facility or dwelling was inspected for signs of sewage back—up. ;
_ZThe site was inspected. for signs of breakout..
All system components; jocluding the SAS, have been located on the '
site.
IThe" 3Qanholes were uncovered, opened, and the interior of
the was was inspected for condition of •baffles or tees,
material of construction, dimensions, depth of liquid, depth• of
sludge, depth of scuii..
The size and location• of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods. .
--L/— The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance '.of SSDS.'. .
Recom..m.endat.ion.6
1 . Cezzpoolmu 6t .Pe 'pum.p.ed. I
2. Pae,5ent .�yat.sm. muet ^e om-itted and a t.iUa .i_Ln.
s�pt�c zy.stem Le ia6tal&d.
SUBSURFACE SEWAGE DISPOSAL SYSTEX INS PECTIONrFORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS:'
If residential
number of bedrooms
number of current residents
garbage grinder, -yes or no
laundry connected to system, yes or no
seasonal use, yes or no
If nonresidential, calculated flow:
Water meter •readings,. if available:
Not me.t.c.¢ed
occ.u.oizd Last date of occupancy
GENERAL INFORMATION . J I
Pumpin ecords and ounce of formation: 7lo?yl � �11),5�.is . sf/9
� 9 'Ter Jo ' r, G
Omn •k r m c y
NO System pumped a•s part of inspection,. yes, or no
if yes, volume pumped i
Reason for pumping:
, Type of system
Septic tank/distribution box/soil -absorption system
-�S- Single cesspool
No Overflow cesspool
NO Privy ,
- yn Shared system .(yes or no) (if yes, attach previous inspection ,
records, if any)
Na&L- Other (explain)
Approximate age of ,all •components. Date installed, if known. Source of
/sa:7�
'information:.
4ny ...o:e�j_.._....__..-...._..... . ..__......_-....-........... -__...._.__........-._..._-.......... ._ ...-.
NO Sewage odors defected when arriving at the site, yes or no
9 i
SUBSURFACE SEWAGE DISPOSAL SYSTEM 'INSPECTION FORM
PART B
V, SYSTEM INFORMATION continued
SEPTIC TANKWONF . .
(locate on site plan)
depth below grade: i
material of construction: *concrete metal FRP other(explain)
dimensions:
sludge depth i
distance from top of sludge to bottom of outlet tee or baffle
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 .
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet. invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
NONE
DISTRIBUTION BOX:'NF
(locate on site plan)
depth of liquid level above outlet invert
Comments:
.(note if level and distribution is equal, evidence of solids carryover,
evidence of leakage into: or out of. box, recommendation for repairs, etc.)
NONE
� j
• i
I
PUMP.: CHAMBER: NO.Ne
(locate on site plan)
NON-` pumps in working• prder, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, •
recommendations for maintenance or repairs,etc. )
Nn•N f
i
v 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued T
i
SOIL ABSORPTION SYSTEM• (SAS) : XXXX.
'(locate on site plan, if possible; excavation not required, .but may be
approximated by non-intrusive methods) .
If not determined to be present, 'explain:
TYPe•
leaching pits and number NONE.'
leaching chambers and number NONE
leaching galleries and number NONF_
leaching trenches, number, length NONE
leaching fields, number, dimensions N NL:
overflow cesspool, number NONE
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc.)
NON£
CESSPOOLS (locate on site plan) :
number and configuration
depth-top of liquid to, inlet invert _0va
depth of solids layer 76
depth of scum layer 12
dimensions of cesspool, U x7
materials of. construction conc.2e.te giockz'
indication of groundwater NONE
inflow (cesspool must'-be pumped as
part of inspection) NO,VC
Comments:
(note condition of soil, signs of hydraulic failure,- level of ponding,
condition of vegetation, recommendations for maintenance or re�airs,etc.)
San & < itay,, 0. N, A112 A Nud2ruP_�c .�cciPu2e oa. noRr/4a,2. V,.zgv_ a.tio '
H64-aae. Leon_/2.00i . .tn f_J_-e4eG.io er4/a(,1C4-4-TJ:re,3b/20o nw.6 '..tee rU.T/1n_. .
I
PRIVY: NOTE
(locate on site plan)
-materials of construction NONE
dimensions
depth of solids I
. Comments: �
(note condition of soil', sighs of. hydraulic failure, level of 'ponding, �-
condition of vegetation,• recommendatibns for maintenance or repairs,etc. ) •
N0 NE
1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION •FORM
PART 8
;. SYSTEM INFORMATION continued - ` •" r ' ;
SKETCH OF SEWAGE '
I'SPOSAL SYSTEM;. : ,•, �� ' �' rr��
include •• : . `;;. r
ties to at least two permanent I references landmarks or benc hmarks-locate all 'wells within' 100' l oov w-4I
:'} �t...e•.. ♦�ke.r r l'.p � C mil;rf ,, ,r. ' .''�
' "'.+ .t„ , - . .t. .�-.:- i,.t+4 �i[yi�'� i -jig"..'f,, •F ,+
' •' ,.i ti. .. � - ,- .=yam �' ; • �,, y�• : ;+
�� . . j S<t..sr�., ?d .w • ';h:7y��S•.
• yNri H-r�r^•s' �-. �:t.*'. I.:-� r(t�,7 �� �, ;'s� r�4 r.'KY r ' +^� � e! s.r t �� .
�f + ' ± + � Ire � •: r-
7 & `
' L, � - <' - �.y rti a i . r�Xx.,�;.�{�� 14K�• ., r �r
r ��r i ; � \'' 47•f�"y•. ' tit.t` -�r:4y ,•{¢,{." t iT •y -4 �,
S A i � ^1 ' . ):. 7✓'�. ,y 3�Y r�'�j r �1:,. � � t t
}_ •,J� 1, � 4' '(I(' ; • Grt':C t K�.L a a5.�.r��� ,C �. � -I.,r
•..'L •i•r�ir�. 1�� �a.t �tr�s t. S Ytr rr(:ii: t.[.C'v,�•11 2 C ,+��r� ••� �+• •�- •1••'
. .•� -�. �L ..y.!•• r. jCr j:�r� r r• :} t t!. f �. .F 7 `V 1 r f 'li •n+ �• -0j.' l� `.t 1
,�,. � ��'•� r.f T J• 1r/Z i,'-�. 'tfx 3t �.}� .r i
''� '2�=�.* ,••. 1. , -t: . ', �' r 'R�..;V 1. : t.� i Jy Yr`','�i-• •�� t��' ', i R' .t .,v••.�
• - , r - al � «t r t c v l6t rtit •Y. ��Y�M' '' � f a•,�.» f
. is � �f'�r +4t r.r ., •�.�
32 Czar!r,Pat
DEPTH- TO, GROUNDWATER r' "►'
depth
groundwater •" {,
method 'of d ti
7-� ermina on or a proximation: '•; aT � .; ; ,,'
,�
(Z FAO
- .. I �) ��'� •ate i`t t 1
12.:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined• (Y, N, or ND) . Describe 'basis of
.determination -in -all instances. : If "not determined", explain why not)
07 Backup of sewage into facility? '
Discharge or ponding of effluent to the surface of the ground
surface waters?
Static liquid level in the distribution box above outlet invert?'
. �. Liquid depth in cesspool • <6" below invert or available' volume< 1/2 day
flow?
_ Required pumping 4 .times or more in the last year? , .
number of times pumped
AhW Septic tank is metal? cracked? structurally 'unsound?. Substantial.
infiltration? substantial exfiltration? tank failure• imminent? 1
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
N� within 50 feet of a-.:surface water?
within 100, feet of a surface water supply or tributary to. a surface
water supply?
within a Zone I of a public well?
�/ 11 within 50 feet of a ,bordering vegetated wetland or salt mars4 '
(cesspools and privies only, "o the SAS)?
- within 50 feet of a private water supply well?
less than 100- feet but greater than 50 feet from a private water
supply well with no".•acceptable water quality analysis? If the well
has •been analyzed to be acceptable, attach copy of'well water anal,
.for coliform bacteria,. volatile organic compounds, ammonia nit ogen and nitrate nitrogen. r
✓• !ipT'-f"��•e� rr.-_T:-r�.�r..:..rr.:-•.... .:A�l.:.rrl sts�tTl r_TCrt ..._ -.. _.. .-. .. - .Tsrr.rr-•r.�T�.r..T.—
TOWN OF ha-#:• .3+�aI P_tf BOARD OF HEALTH
SOBSORFACE SEWAGE;' DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION
-TYPE eR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS 32 jCe.nn_.ital Pal ton Dlt .ve. Ryan.n.i,6111a-a.6.
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME 41-iXg'-'-n# Don..2daon 9 Dozo: t ty
~ --- -- PART D - CERTIFICATION I
NAME OF INSPECTOR �•�• �lac.oirz�c:a �2,
COMPANY NAME a• P.Nad.)m4e2 & Son lac-0
COMPANY ADDRESS Box 66 02632
Street To►m or City Stat• LIP
COMPANY TELEPHONE (508 ) 775 3338 FAX (508 ) .'790 - 1578
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system 'at
. this address and that the information reported is true , accurate, and
complete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on-
site sewage disposal systems.
Check one:
_•Y."System PASSED
The inspection which I have conducted has not found any information
which indicates thaf;` the system fails to adequately protect public
health or the environment as .defined in' 310 CMR 15. 303. Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
XXXXXX System FAILED*
The inspection which I have conducted has found that the system fails to
protect the public Health and the environment in accordance with Title
.5 , 310 CMR 15 - 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form.
Inspector Signature Date
One copy of this c .ification must be provided to the OWNER, the BUYER
'(where applicable ) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or"'o' orator shall u
P pgrade ' the system
within one year of the date of the inspection, unless allowed or required
otherwise As provided in 310 CMR 15 . 305 .
partd.doc
tP
Ccn^.rronweaan ct Mosscrq....Vens i
ExecurNe Office cr Envuor•,r�,enicc,htfc.,s
Department of
ental •Protection
Environm . ... .. . • . - . : -•
' Water Pouutlon Ccnnol tecnruccl Assmonce and troiNng�ecnons
w.a
Trudy Cox* • ;""
Thom"IL Powers
' � Wit` , � ,:� r •i
06/12/95
ATTN: 'Joseph P. Macomber, Jr.
Joseph Macomber and Son
PO Box 66
Centerville, MA 02632.
Dear Joseph P. Macomber, 'Jr. , _
;.
I am pleased to inform you that you have attended training, met
the experience qualificationsy`:and have passed the Title 5 System
Inspector• exam, pursuant to 310 CMR 15.340. The passing grade for • ,
the exam was 39/52 or 75%.
This is an official notification that you are a Certified Department
of Environmental Protection System Inspector pursuant to 310 CMR 15.340.
a
You will receive a System -Inspector certificate at a later date.
If you have any futher questions, please write to me at the following'
address:
Kimball Simpson
• U.E.P. Training Center
50 Route 20
Millbury, MA 01527
Thank you very much for your time and consideration in this matter.
y :1
Sincerely,
va
Kimball T. Simpson,
DEP Training Center Director �
(2405� Row ZO • ��d�4ury, MA 0�'..' • FAX 606-755-9Z33 • T•1•unune 608.756-Teel
. i
Water
v
Conservation
SAVE Tips . : .
ME! p
CHEGK FOR LEAKS
Water Loss in-Gallons Due to Leaks -
•Leak
this- Loss Per Day. L'oss Per Month
Size
• 120 3,600
360 10,800
693 - 20,790 r
1,200 36,000
•1,920 57,600
3,096• 92,880.0 4,296 128,980
® 6,640 199,200.
6,9.84 ' • 200,520
80-424 252.720
® 9,888 296,640
® `
11,324 339,720
12,720 381,600
..y y.
14,952
448,560 .
OCT 03. '•95 04:41PM P.1i2
JFI _ 1 ,
FACSIMILE TRANSMISSION
TO:
FROM.
RE
COMMENTS:
70
r x
I 1.
i
-7.
T
t
If you have problems with the transmission, please call (508) 778 - 4005.
NUMBER OF PAGES INCLUDING THIS COVER SHEET:
DATE: Z-2Ar T1ME:
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JOSEPH P. MACOM,B R SON INC. `'; � ,wood w
9/18/95 _i
Mr Thomas A. McKean
Agent of the Board of Health
Town of Barnstable Public Health DIV.
367 Main Street
Hyannis ,Ma. 02601
Dear Mr. McKean,
On June 9 , 1995 we had the cesspool pumped at property we own at 32 GENERAL
Patton Drive for the first time in almost 3 years .
WE made a decision to put the property up for sale,sowe thought it wise to
have the system inspected to know what we would be facing financially to
bring the system up to title 5 before sale ( if any)would be finalized.WE
expected it to fail knowing the age of the property.
To our amazement we received a call from the inspector saying the cesspool
was filled again,then in his report to the town he stated it was backing up
into the facility so we had it pumped immediately by MR Macomber & SON, INC.
(SAME CO . DID INSPECTION. )
WE received an order to comply letter from your office dated 9/27/95 giving_
us thirty days to do so. Our friend and real estate agent Ms . Helen Baker
with B and K Real estate in Centerville tried to help us with the situation
to no avail .We never thought to ask our tenant Mr WYNN anything about the
problem until yesterday - 9/17/95,Mr Wynn said he never had any back-up from
the cesspool into the facility since being there .He said if he had he would
have let us know immediately,he also stated he would sign any statement to
this effect, if needed, so we are including his signature on this letter .
We are asking you for a years extension. If property is sold in meantime we
know we have to comply before sale is finalized.
Looking foward to hearing from you by return mail ,and thanking you inadvance,
Yours Truly,
Wilbert Donalson and Dor by P. Donalson
3099 . Tamarack Way
Mira Loma ,Ca . 91752
Pho. 909 681 9725
Mr Wynn have resided at 32 General Patton Dr. for three years and his signature
appears below.
J
Charles _E;. Wynr1S