HomeMy WebLinkAbout0051 GEORGE STREET - Health -� 51 eorge Street
Hyannis
A = 291 090
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TOWN OF�BLARNSTABLE �.c,
LOCATION • r� ✓ SEWAGE # -20 9
VILLAGE ASSESSO MAP & LOT 0
INSTALLER'S NAME& PHONE NO.
SEPTIC TANK CAPACITY
LEACHING_.FACILITY:-(type) (size)
NO. OF BEDROOMS p I
/y
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: 4Y
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) —low,/w,4 '"/4 Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) A✓�� Feet
Furnished by
1
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`A`qn•
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No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
' Yes
t PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZippliCotion for Mi!6tloe;a1 bp$tem Con!Arurt.ion Permit
Application for a Permit to Construct( . )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. S//_ e CL UVA��I Owner's N Addis and Tel.No. �/�
TI J I►n JClr,1
Assessor's Map/Parcel ` C fi SO 1
Installer's Name,Address,and Tel.No!(/ Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building <j lo YA.0 o. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow (/ gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
. t
Nature of Repairs or Alterations(Answ r when applicable) i
I
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu by this Boarlt .
Signe o Date
Application Approved by Date
Application Disapproved for the following re, ns
Permit No. aiqnk —Iorvaw Date Issued
(/
No. Fee �
THE COMMONWEALTH OF MASSACHUSETTS Entered i1.n computer: Yes
PUBLIC,HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
e Ztppliration for 30iopo6al *pgtem Congtructton Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) El Complete System ❑Individual Components
I '
Location Address or Lot No. Owner's NaAdd s and Tel.No.
s/Gea 2 Uvs cu. j ;2 Z o/d _,V
Assessor's Map/Parcel Z �� �0 SO r
Installer's Name,Adds, d Tel.No, Designer's Name,Address and Tel.No. i
Type of Building:
Dwelling No,of Bedrooms / Lot Size sq.ft. Garbage Grinder( )
Other Type of Building51-1,114 lew++ o.of Persons Showers( ) Cafeteria( )
Other Fixtures /)
Design Flow �yl/ gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
t
Description of Soil
t V 1
Nature of Repairs or Alterations(Answ r when a plicable) A/
Date last inspected: / U
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 iss by this Bo of halt .
Signed 9 o Date $0 0
Application Approved b o Date
Application Disapproved for the following rea ns
051
Permit No. Date Issued
————————————————————————————————. ——— •.,'.
n� THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
t I i
I Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded ( )
Abandoned( )by 1
at S Geormp_ H�l .,on n r t haAheem constructyd i)i accordance
with the provisions dYTitle 5 and the for Disposal System Construction Permit NobwYt dated S/3 0 1-/
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the sy tern ill f'u/nction as g.ned.
Date �_ L � Inspector
—— = ————————————————————————————-
No. Ov? Fee
i
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mtgogai *pgte Congtruction permit
Permission is hereby r nted Cons u ( pair grad ( Va"(O
System located at ®
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.
Provided:Cons6uct' n m st be completed within three years of the date of is pe it_
Date: Approved by
i
s.A
TOWN OF,B�ARNSTABLE
• LOCATION r / SEWAGE #
VILLAGE J ASSESSOR MAP & LOT aI I V 9
INSTALLER'S NAME&PHONE NO. 'ee7 & 1 oe
SEPTIC.TANK CAPACITY yy
LEACHING_F.ACIL.IT-X•: (type)�C (size)
NO-. OFBEDROOMS
BUILDER OR OWNER
PERMITDATE: a�-3 COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Tab)v,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) `TOW"/,�1,4la,4 ArIA Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) A/04 Feet
Furnished by
% f� Zq ,
i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT.OF ENVIRONMENTAL PROTECTION
MAP
PARCEL O `
L07 U
TITLE 5 I
OFFICIAL INSPECTION FORM-NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART-.A
CERTIFICATION t°
S �1�8 7� ►�1 E9 lz-� q w r
Property Address: (Lli tr A "( P 2 9 6
&P A Z;F lrC51( ��N ✓T PS�—� Ct
Owner's Name:
' diet--� a 1 ►.!�f. e �
Owner's Address: � � �� M
y �k12- oUT1 1�OZ 6 6¢ o 7
�- t
Date of Inspection: ¢—Z11--o 4—
Z
Name of Inspector: (pleaseprint) co
Company Name: t�7 25 5J E3 C F_
Mailing Address: 1 TLC D —O)di r79.9 rn
iD I G e 0 2-�✓'6:mod'
Telephone Number: 00 _ 0— 34&t
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:
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
'F 'Is
W�27_'
Inspector's Signature: Dater
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.
• Notes and Comments *L,5—y-9X-M 6)
. .��Pi�ia/6�-n�A 7ds�S •��'GICB� ��ST.�I,�.�,? �/4:�FRY�H�iv�ii✓6P�L 1�J OV 19/4/Q4
y e a,<f ,g,✓o �;g, 5. O,t/ Co is�s e� G�SSPoo�7a-
(�DW,N) �TN�P� C�YG?Z� G'�v��r✓�l/!`9'✓��3 �/v�i9TIf4�•'�1S A�✓O ll�/A/GVPY
�W
y57i✓ dvk/PIT
****This report only describes conditions at the time of inspon and under the conditions of use at
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page I
OFFICIAL TI —NOT FUR VOLUNTARY ASSESSMEIN-4 a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 5'f G B o R G►E ST,
HYAIW td 1 .5
Owner: E Al—se
Date of Inspection:. —6
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:
a tf � -L�D4S �� �i�i�✓� �✓� �c vc�1 uii� s� �f��2IlG�
B: System Conditionally Passes:
On or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The stem,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not de ined(Y,N,ND)in the for the following statements. If"not determined"please
explain.
The septic tank is metal and er 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltratio r exfiltration or tank failure is imminent. System.will pass inspection if the
existing tank is replaced with a complying tic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it i tructurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is ailable.
ND explain:
Observation of sewage backup or break out or high static ater level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution .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 . e system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:.
2
Page 3 of l l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 51 G EO R.G E ST
IrA KW LI r S
Owner:
Date of Inspection: 4- 2• "O
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require fiuther evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. St m will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(b)that the
sy not functioning in a manner which will protect public health,safety and the environment:
Cesspo or privy is within 50 feet of a surface water
_ Cesspool rivy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Boar of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner tha rotects the public health,safety and environment:
The system has a septic tank and soil sorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface ater supply.
The system has a septic tank and SAS and the S is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS i within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less an 100 feet but 50 feet or more front a
private water supply well".Method used to determine distance
"This system passes if the well water analysis,performed at a DEP ce ' ed laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from llution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than m,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ..
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address:
Owner:
_Date of Inspection:
D. System Failure Criteria applicable to all systems
You must indicate"yes"or"no"to each of the following for all inspections: .
Yes No.
_ �ackup 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
dogged SAS or cesspool
_ WAVStatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_✓Liquid depth in cesspool is less than 6"below invert or available volume is less than day flow
✓Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
7Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
ater 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 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.]
WO (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. rge Systems: A11A
To be c idered a large system the system must serve a facility with a'design flow of 10,000 gpd to 15,000
gpd•
You must indicate ' er"yes"or"no"to each of.the following:
(The following criteria a to large systems in addition to the criteria above)
yes no
the system is within 400 feet o urface drinking water supply
the system is within 200 feet of a tribu a surface drinking water supply
the system is located in a nitrogen sensitive area(jnt 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 considere significant threat,or answered
"yes"in Section D above the large system has failed.The owner or operator of any I system considered a
significant threat under Section E or failed under Section D shall upgrade the system in acc ance with 310 CMR
15.304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 1 l
OFFICIAL INSPECTIONIORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: E CRA F— 5 ,
Owner: N E�
Date of Inspection:
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?
as the system received normal'flows in the previous two week period?
_ _ZHave large volumes of water been introduced to the system recently or as part of this inspection?
_4 ✓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?
V*' _ Were all system components,'6Ccluding the SAS,located on site?
_✓ _ Were the oo 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:
Yes n9-
.Existing information.For example,a plan at the Board of Health.
V _ 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(3)(b)J
s
Page 6 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL:SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: Jr f! �9EDQi�E 57%
��aNu19
Owner: 1EA1L
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 4.. Number of bedrooms(actual): 4-
DESIGN flow based on 310 CMR 15.203(for example: 110.gpd x#.of bedrooms): 440A PO,
Number of current residents:
Does residence have a garbage grinder(yes or no): A40
Is laundry on a separate sewage system(yes or no). [if yes separate inspection required]
Laundry system inspected(yes or no):. �
Seasonal use:(yes or no):
Water meter readings,if available(last 2 years usage(gpd)): APAII t-t/S bE /n/��GY.C�JD9�✓�/
Sump pump(yes or no): Ao
Last date of occupancy:G /AV�Sy 2a04
COMMERCIAL INDUSTRIAL NIA
f establishment:
Design o d on 310 CMR 15.203): apd
Basis of design flow s ons/sgft,etT
Grease trap present(yes or no):
Industrial waste holding tank present(yes
Non-sanitary waste discharged to the Title 5 system(yes
Water meter readings,.if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no): D
If yes,volume pumped: N allons—How was.Tiantity pumped determined? , - /
Reason for pumping: Nu Gd3S%�mGt U�/esrtf4x✓S �QB� f�i� p,4y Eo1/D/p'�oN
TYI OF SYSTEM
soil absorption system Clggz?
__.,,,Single cesspool
Overflow cesspool (/°1r)
_Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Irmovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval .
Other(describe):
i
Approximate age of all components,date installed(if kn wn)and source of information:
/�c�9 1 EGG U/21414,1� -3 S ONr /kPQ/6L6g 6112e9 /PAo
al/Zc�- <9 4V -6nA, -i 77VO ,0, Prow,a
Were sewage odors detected when arriving at the sit
.�(yes or no):
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY,ASSESSMENTS
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART-C
SYSTEM INFORMATION(continued)
Property Address: 5 E d R CAE �r
Owner: 4{E ALY
Date of Inspection: 24
BUILDING SEWER(locate on site plan)
Depth below grade: h�VVsIZVZ7.0N' e•,� 9�✓�J �� y Qt� 4'�PA�J�-9�' sFbocS
Materials of construction:_cast Iron 40 C_other(explain a-IZ71 DAJ-2—7 7T4,0'1
Distance from private water supply well or suction line: G / 7ah'O Zo S�s}a.�d /, 7� a•8�
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: locate on site plan)
Depth grade:
Material of co coon:_concrete_metal_fiberglass polyethylene
_other(explain)
If tank is metal,list age:_ e confuTned by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or
m Scu 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:
How were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,struc tegrity,liquid levels
as related to outlet invert,evidence of.leakage,etc.):
GREASE TRAP: (locate on site.plan)
-Depth ade:_
Material of co ion:_concrete_metal_fiberglass polyethylene_other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top.of outlet tee or
Distance from bottom of scum to bottom of outlet tee or
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle co n,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
• Page 8 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:' S� 3
Owner:
Date of.Inspection: •
TIGHT or HOLDING TANK:N14 (tank must be pumped at time of inspection)(locate on site plan)
Dep low grade:
Material o truction: concrete metal fiberglass_polyethylene �other�(explain):
Dimensions:
Capacity: Ions
Design Flow: gallo
Alarm present(yes or no):
Alarm level: Alarm in working order(yes o
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX:4'14-(if present must be opened)(locate on site plan)
Depth o above outlet invert:
Comments(note if box is a 'bution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: (locate on site plan)
Pumps in�varl ' rder(yes or no):
Alarms in working order o
Comments(note condition of pump c dition of pumps and appurtenances,etc.):
. 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEMINFORMATION(continued)
Property Address: 51'. �S�
H�,p rJ tJlS
Owner: e
Date of Inspection: - •04
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type .- - ���r � ' '• '`' �' ! �,
✓leaching pits,numberzWE'% S/�ff'lLf¢ ® .">lZ
leaching chambers'number:
44C,4 IWZ i�F P165
leaching galleries,number:
leaching trenches,number,length: B 27� L/W& u1/2
QTo+-—�,7-leaching fields,number,dimensions: ilo. Z Z 'D.G' A 4c) .r
91j D
0 To��overflow cesspool,number: t6 - , . - �k+e—caCl
umovative/alternative system Type/n a of technol i A-
Comments(note c t' soil signs failur evel f po ding amvp s 1' cond'ti of ve elation
etc. : . �' J�j j el9f S, I �u hg� w.t%
�GN/A14 f /'7'� DAP &?,D4 9/r/o�4?0 719'��S1.QC, �/iYl 7� /77:L/�e'(�
y y
Aga o1�02
ND V6 Couf/{6-77o�t/ol-e- So/C
CESSPOOLS:� umpe(cesspool must a p as part of uispection)(locatg on site plan rFUM
c 6V l
Number and configuration: Tvo -5ICSYU¢ L�1 L /A✓KONLy'
Depth-top of liquid to ' let invert: ,60 f.APA 4--da,917 04/ 7 r,
Depth of solids layer: h tioN-5 s 0
Depth of scum layer: N �D •'i•
Dimensions of cesspool: f�w'/ f
Materials.of construction: &oA✓C GocK* _ _,_, _ . . " .. "W �� •
Indication of groundwater inflow(yes or no): 6' �` +'' " ` iEs,
Comments(note c�d''t'o of soil,si of h draulic it e,level upon ,conditio o ve eta n etc "`jf
�� W&r 5UI,/ ¢O w Di Ff 7'D ce4YP 1a T Ta' SED c3"//fF D D 1E
C Z o SrA 6XI s>/a/6 .ZYisT#CG 2 AOrt -
G@ AM5 ! �7 z4"7 z¢'Tfs—
�,VAca ite plan) y IIVZ67-1
a fconstruc / '�BGrcoc.J SST O-a3. (K1��y�Nk)
cI
Bi=Znsions:
Depth o
P u�l Pit G• /.TFL .
Co note con soil,signs ulic failure, onding,condition of vegetation,etc.):
,8oT7f G63S�bOGSQ! ® ��d/D<T/[��j. �641J/�6Q
/Q 1671 q i¢-S 86p774�,71-VK `�✓v�l/L6+3Lh'/�/4) D f 5�B6D�.4s+70_i9 �'?'Y9 v�i "
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 aiaO ;�4L--
;4 r.!
Owner:
Date of Inspection: -2 -e4
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or .
benchmarks.Locate al ells within 00{eet, ,ocate where public water supply enters the building.
IN L.V )
f 46 '
3)22�.3" '(5) & .
DATA 44 -L" DTN 41Xr d'IC i `J
1 6 ` r ---- - --
10
Page 11 of l 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C +
SYSTEM INFORMATION(continued)
j Property Address: 5 CiE024E 57,
Owner:
Date of Inspection:
SITE EXAM
Slope !l
Surface water P,1-9n1Y'_
Check cellar DR y
Shallow wells^/dnl,�r
Estimated depth to ground water 713 feet
Please indicate(check)all methods used to determine the high ground water elevation,
A11 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)
Checked with local Board of Health-explain:
Checked-with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You.must describe how you established Ihe high ground water elevation:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form _tq- j�j
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / q
51 George St 2?( —�
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is required for Hyannis MA 02601 9-10-08
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.
A. General Information
1. Inspector:
Shawn Mcelroy ( ;
Name of Inspector
Upper Cape Septic Services
Company Name 1 co,
29 Atwater Dr .pp
Company Address 70
E. Falmouth- LO
MA • Z 02536 =
City/Town State ip Code W
1-508-495 0905 S13971 0 '
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
9-11-08
Inspector's S gnature 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.
v .
****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. I I r i 1/2c d f
System has three cesspools overflowing into a leach field all in good working order.
t5insp•03108 w Tltle 5 Official Inspection Form:Subsurface Sewage Disposal stem•.Page 1 of 15
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i
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r
Commonwealth of Massachusetts
Title 5 Official 'Inspection Form 5
Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments ''
M 51 George St
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is required for Hyannis MA 02601 9-10-08
-
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System has three cesspools with a separate leach field. All seem to be in good working order with no
sign of failure.
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 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.
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 •<
El obstruction is removed
t5insp•03108 Trtle 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 George St
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is required for Hyannis MA 02601 9-10-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ 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
❑ obstruction is removed
ND Explain:
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.
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
o- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 51 George St
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is required for Hyannis MA 02601 9-10-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 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 67 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.
a ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 George St
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is Hyannis MA 02601 9-10-08
required for H y `
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) ,
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No i "
❑ ® 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 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.
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.
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 George St
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is required for Hyannis . MA 02601 9-10-08
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate eyes"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)]
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 George St
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is required for Hyannis MA 02601 9-10-08
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 440
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 7-08
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:
Last date of occupancy/use: Date
Other(describe):
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts i
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form :Not for Voluntary-Assessments_ f
51 George St t
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is required for Hyannis MA 02601 9-10-08
--
every page. City/Town State Zip Code Date of inspection
D. System Information (cont.) ,
General Information
Pumping Records:
Source of information: Bluewater 9-10-08 900
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 900 Gal
gallons
How was quantity pumped determined? reciept
Reason for pumping: Required for inspection
Type of System:
❑ Septic tank, distribution box,•soil absorption system
❑ Single cesspool
® Overflow cesspool
❑ Privy 1+ 1 -.
❑ 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): c°
System has three cesspools with a separate leach field.
Approximate age of all components, date installed (if known) and source of information:
1960's and 1990's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 George St
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is required for Hyannis MA 02601 9-10-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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: feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 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:
Sludge depth:
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
How were dimensions determined?
t5insp-03/08 TiUe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
I- '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage.Disposal System Forme-Not.for Voluntary-Assessments.
51 George St
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is required for Hyannis MA 02601 9-10-08
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.):
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.):
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):
t5insp•03/08 _ Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 10 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 George St
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is required for Hyannis MA 02601 9-10-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 George St
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is required for Hyannis MA 02601 9-10-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
i
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
1-16'x22'
3
® 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.):
Cesspools in good working order with leach field showing no sign of failure.
t5lnsp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
I
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
51 George St
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is required for Hyannis MA 02601 9-10-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools(cesspool must be pumped as part of inspection),(locate on site plan):
Number and configuration 3-Inline
Depth —.top of liquid to inlet invert Empty
Depth of solids layer 6
Depth of scum layer 0
Dimensions of cesspool 6x6
Materials of construction Block
Indication of groundwater inflow ❑ Yes ® No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Cesspool in good condition with baffles installed.
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-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts ;
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments
51 George St
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is required for Hyannis MA 02601 9-10-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch 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.
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t5insp-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth -Not for Voluntary Assessments
51 George St
Property Address
Saxon Mortgage Services
Owner Owner's Name
information is required for Hyannis MA 02601 9-10-08
every page. City/Town 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:
i
Town maps and USGS maps show groundwater at 15'.
tSlnsp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15