HomeMy WebLinkAbout0014 GREENBRIER LANE - Health 14 GREENBRIER LANE
HYANNIS
A=268-078-004
Commonwealth of Massachusetts 02&8 0-n _Opll
Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
14 Greenbrier Lane
Property Address
Elaine Stilianos, TTEE
Owner Owner's NamJ� r .,'r,
information is Hy annis ✓ MA 02601 11/12/2020
reguired for every a`r ^c
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 on the computer,
use;ggLy,b#4e tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
52 Rivers End Road
Company Address
Teaticket Ma. 02536
Cityrown 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 rriy -
}Y 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'determiled"
~:•_=:k_- ' that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
. .t 11/13/2020 t ft
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.
iy
i5in' `doc`--rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•P�•eA`oft18'sP° P 9 P Y � ,...
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ yI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
14 Greenbrier Lane
Property Address
Elaine Stilianos, TTEE
Owner Owner's Name
information is required for every Hyannis MA 02601 11/12/2020
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 an H-10 1000 gallon septic tank with an H-10 D-Box feeding-a-precast-
r.,,... leaching pit with 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"-I-"not-------
determined," please explain. v
F,. 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
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c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
` 14 Greenbrier Lane
Property Address
y Elaine Stilianos, TTEE
Owner Owner's Name
information is required for every Hyannis MA 02601 11/12/2020
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 d,ue,,,._
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
jx
❑ 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:
a ,
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18-i%.n ';= ;4,_
Commonwealth of Massachusetts .tk,
Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
14 Greenbrier Lane
Property Address
Elaine Stilianos, TTEE
Owner Owner's Name
information is required for every y H annis MA 02601 11/12/2020
City/Town/Town State Zip Code Date of Inspection,
page:..,;.. � Y P P
C. Inspection Summary (cont.)
tsas�iik` —JC "A -. .
❑ 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:
yq r.; ❑ 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
P 9 9 q
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: lI C W.'
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
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
14 Greenbrier Lane
v Property Address
Elaine Stilianos, TTEE
Owner Owner's Name
information is required for every Hyannis MA 02601 11/12/2020
page. Cityfrown 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"awoverloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume'is less
❑ ® than 'h day flow "
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than.50.feet_.
from a private water supply well with no acceptable water quality analysIiis:[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 CM 15.303, therefore the system fails. The
Y system owner should contact the Board of Health to determine whet Will' ^'
necessary to correct the failure. an
5) Large Systems: To be considered a large system the system must serve a facility with a..r
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
s:t
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
rn ..
the system is located in a nitrogen sensitive area (Interim Wellhead�Proteetion;,.
El El
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5bf�1'8''
Commonwealth of Massachusetts
?� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
!% 14 Greenbrier Lane
Property Address
Elaine Stilianos, TTEE
Owner.:. Owner's Name
Information is Hyannis MA 02601 11/12/2020
required for every y � + .
page.`.`::' CityTTown State Zip Code Date of Inspection }#
s,
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 Bonard of Heal#h
El ® 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? x t-
4
® [IWere all system components, excluding the SAS, located on sites
® ❑ 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:
i ® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part G.is�atsissue
approximation of distance is unacceptable) [310 CMR 15.302(5)] s'sl
r .
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V 14 Greenbrier Lane
Property Address `
Elaine Stilianos, TTEE
Owner Owner's Name
information is required for every Hyannis MA 02601 11/12/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
E=5:.
Number of bedrooms (design): 3 Number of bedrooms (actual): 3 ,u
330!plii5r;
: - DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): GPD
- Description: f
Number of current residents: 0
Does residence have a garbage grinder? ❑' Yes '`No
Does residence have a water treatment unit? .r
❑ lies�Z;-No-
If yes, discharges to: 'r
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d town water
9 ( Y 9 (gP ))�
Detail: Yes
y .N: .
The past year- 132,396 gallons were used
Sump pump? ❑ Yes ® No
Last date of occupancy: Oct 5th
Date
�r'F
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
2
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
I; Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
14 Greenbrier Lane
Property Address
Elaine Stilianos, TTEE
Owner Owner's Name
information is H annis MA 02601 11/12/2020
required for every y "i �>-•-
page. City/Town State Zip Code Date of Inspection",
D. System Information (cont.) ;� .{
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
'),nrrr:c
Grease trap present? ❑ Yes ❑ No
%�'7= Water treatment unit resent? ry
P ❑ -Yes ❑_
' ;:c
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 1 *,e,a .r;
How was quantity pumped determined? '
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
I -
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a 14 Greenbrier Lane
Property Address
Elaine Stilianos, TTEE
Owner Owner's Name
information is Hyannis MA 02601 11/12/2020
required for every '
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool s "�°F ►
. ❑ 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.
5;
',. ❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
1979
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade:
2611
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.):
4
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts n..
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
14 Greenbrier Lane
u�
Property Address
Elaine Stilianos, TTEE
Owner _ Owner's Name
information is Hyannis MA 02601 11/12/2020
required for every y I
page.•; City/Town State Zip Code Date of Inspection
D. System Information (cont.)
<�<'} 6. Septic Tank(locate on site plan):
1811
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: H-10 1000 gallon
Sludge depth:
2"
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 13„
How were dimensions determined?
sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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 baffle was in place.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
I -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
14 Greenbrier Lane
Property Address _
Elaine Stilianos, TTEE -
Owner Owner's Name
information is required for every Hyannis MA 02601 11/12/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
-------------
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
— Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date -
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structual;i'tifegffy',
ti 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: ---- _ ----- __-
M ,. Material of construction: -
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
in
y Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 A of 9$n y,'
,..
160.04,
LOCATION / ___31-WAG PERMIT NO.
VILLAGE
INSTAL R'S NA i ADDRESS
c�✓v�
B U It D E R OR OW ER
DATE PERMIT ISSUED _Zz_'►9
DATE COMPLIANCE ISSUED _
T � z� 72
0
bN
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V � 14 Greenbrier Lane it
Property Address
Elaine Stilianos, TTEE
Owner Owner's Name
information is
required for every Hyannis MA 02601 11/12/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
.=_°:� Alarm present: El Yes ❑ No
11=-- 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? El Yes ❑ No
:n
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 011
_.Y.
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.
X,r: -
Gz
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
t,
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
110 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
14 Greenbrier Lane
_.f Property Address
Elaine Stilianos, TTEE
Owner.information is Owner's Name
requred,for every Hyannis MA 02601 11/12/2020
page. Cityrrown 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.):
v
* 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:
One
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length: -
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
1p Title 5 official Inspection Form
III; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
14 Greenbrier Lane
Property Address
Elaine Stilianos, TTEE
Owner Owner's Name
information is requi1d;,for every Hyannis MA 02601 11/12/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
n 11. Soil Absorption System (SAS) (cont.) 4`
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
t 'N Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
. T
j
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments - - - -
1,
V. 14 Greenbrier Lane
Property Address
Elaine Stilianos, TTEE
Owner Owner's Name
information is required for every Hyannis MA 02601 11/12/2020
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.):
a 7
-
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
14 Greenbrier Lane
Property Address
Elaine Stilianos, TTEE
Owner Owner's Name
information-is Hyannis required'for"every -Y MA 02601 11/12/2020
''` City/Town State Zip Code Date of Inspection
page>`xr` Ci /Town "
D. System Information (cont.)
%� 14. Sketch Of Sewage Disposal System:
,152.1
�` ' 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
paces
4
t � f
0� Jy,
t
t5insp.doc•rev.7/26/2018 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;
14 Greenbrier Lane
u Property Address
Elaine Stilianos, TTEE
Owner Owner's Name
information is required for every Hyannis MA 02601 11/12/2020
-
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 14 plus feet
feet
Please indicate all methods used to determine the high ground water elevation:
ElObtained from system design plans on record
If checked, date of design plan reviewed: Date
.. r.h.
® 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 to show 4 plus feet of separation.
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
.i.,.
;;. Commonwealth of Massachusetts
Q.-
Title 5 Official Inspection Form
11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v—
14 Greenbrier Lane
Property Address
Elaine Stilianos, TTEE
Owner Owner's Name
information is required for every Hyannis MA 02601 11/12/2020
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:
:�s r;:_• 1, 2, 3, or 5 completed as appropriate
" 4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached _For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
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No.............`.... Fps..... -
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HFALTH
Wit s^/.................0F.`0 4 fly_
...............................................................
Appliration for Disposal Works Tonstrnrtiun Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
.................. .....
al/ l !...:`...... ...F.:���l..v�,(°�/.✓/� C!/��.:3........ ........................................•.
e A Loc 'on-Addre
t No
sue' /. ;� Tt��.�f .........................
` _ Owner Address
.....ai.rz __°_. :.. °.r r'......................................•• 5o
Pq Installer Address
s ..�.._Sq. feet
U Type of Building Size Lot._ -. _L? �
0-4 Dwelling—No. of Bedrooms............ ..........................Expansion Attic ( Garbage Grinder )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
d Other fixturgL...........................................................................................................
.... ...
W
Design Flow. `�f............ ....... lions per person per day. Total daily flow.....
9 Septic Tank Liquid capacity.......... Ions Length................ Width................ Diameter................ Depth................
Disposal Trench .._.______._ Width...14........ Total Length.....r.�..._..__ Total leaching area__o�K.......sq. ft.
-----
Seepage Pit No.. .... ........... Diameter.._..__..__......... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing t4nk j ) ��
Percolation Test Results Performed by._..�p_t��' :y _ �� -._ �1 1 "
4 Test Pit No. I................minutes per inch Depth of Test Pit_....../�� Depth to ground water........................
r1rq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
. .
f - 4
O Description of Soil...d�. !.....................ra/ ,, ........................
.f /` r�1 ......rC�-fZ�_��,...tl..I� �ApG
x ---
U _..........y-----------------•-- .•....-•------------........-•------••----------------------------•-•----------...------••--•------.....................•-•--•-••-----•-
V Nature of Repairs or Alterations—Answer when applicable-----------------------------------_............................................................
---------------------------------------•------•-------•-----------------•--....-----•-••---.....-----------...---------------------------------•------------------•----•-------------........_..........
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLIT= 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the oard of healt
jSign r9
•--•--•---...•••-•.....•-•-••--•---.....••.....••-•••.... ��-
Date
Application Approved By••••••-••. •-• ..... ......................................
..... -,2 'z `-7
Date
Application Disapproved for the following reasons__________________________________________
.................................................. ..........._
.........-•-----------------------•----......_....---------...-----•--------....---•---•...------••..--
Date
PermitNo......................................................... Issued...... .: '7' . .....................
Date
A FxR...............
THE COMMONWEALTH OF MASSACHUSETTS
BOAeRD OF HEALTH
710
. .............................0 HEALTH
............................................. ........................
41
AppliratWu for Disposal Works TunstrUirtion rnmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at: o
/?
................... .................................................................................
Location-Addr or Lot No.
........................ ...................................
Owner Address
f4
Installer Address
M .. /�� feet
Type of Building Size Lot ............
Dwelling—No. of Bedrooms............ .............................Expansion Attic (1-1 Garbage Grinder NA..
04 Other—Type of Building ............................ No. of perlson's........................... Showers Cafeteria
0.4 Other fixturCL.................................................
----------------------*-----------------------------_'=4------------------------**-------------------
Design Flow .......;;�,e............ lions per person per day. Total daily flow............�) '72-4 ................gallons.
W � .'" —_;_el ................
Liquid capacity...02...... lions Length................ Width..." ......... Diameter..._......_..._. Depth_...._..........
1:4 Septic Tank�_ ------ I'I... —
W ........ '45 6
Z Disposal Trench ------------ Width.._el��.......... Total Length.....K... Total leaching area.. ..............sq. ft.
Seepage Pit No.;—. ..�........... Diameter.................... Depth below inlet..............._..__ Total leaching area..................sq. ft.
Z Other Distribution box Dosing tank
Percolation Test Result's X,
.........X-/2 Date......5V....Performed by .............,................ I------ !�/---------/--------
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water._......................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water:...._..._.........._._.
. .............>.-.
,;7;:�........I :-/);,.... .........................................................................................
0 Description of Soil-- 4A, 6 - -- , 7 ..... ..Z..,.ne
......................................................... ... ...............
UW --;,,-"***�'�--------t,,','�/------------------"----------------------------------------**--------------------------*---------------*---------------*---------------------------------------------------
Z ......................................................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T!TL_ 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a.Certificate of Compliance has been issued by the board of health.
_�, 7 �
Sign .. .......;.j.'
Date
Application Approved By......... ...... ..................... 4/,,
...........
Date
Application Disapproved for the following reasons:.................................... .
----------------------------------------------------------------
........................................................ ................................................... .
............................................................................................
Date
Permit No.......................................................... IssuedL...{�..— .............
Date
THE COMMONWEALTH OF MASSACHUSETTS
11
BOARD OF HEALTH
...... ..............................OF..... ......................................
(Intifirab ,of outplianrr
4
THIS IS TO CERTIFY, That the Individual Sewage 't,)isposal System constructed (�or Repaired
by.. L.-e" AVY",. ....................................................I .........................................................................I................
Installer
at.................................... .............................................;/
_` ------ ---- ----- ------------f, -------------------------I.......111*11,11,.............
has been installed in accordance with the provisions of F 5 of The State Sanitary WCde as described in the
_ ___-_ _ 1�dated---
application for Disposal Works Construction Permit No. .. ........ ....... . .. ........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....... ..................................... Inspector........./..... ----------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.....................................OF..............v..1..................................................................
NFEE........................
Disposal ]Vorkg 015onstrurtion "pamit
Permission is hereby (ed)=
an Individual7-SewageDisposal System...
....................................................................................
to Construct (A )..or. Repair
Street
as shown on the application for Disposal Works Construction Pepnii �ated..........
11��10
%16' _' -----------------------------
Board of Health 7
DATE......0/._'r A -� ��-
---------...........................................
FORM 1255 'HOBBS & WARREN, INC.. PUBLISHERS
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