HomeMy WebLinkAbout0075 GREENWOOD AVENUE - Health Greenwood`Avenue
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No. �a Fee 'J
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2ppliLation for Mispo8al *pstrm Construction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon(A ❑Complete System ❑Individual Components
Location Address or Lot No. rl C:0,$Y,lL)c-VZj A 6 Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel I 0o ydf S. e U--;j3 "AR1NA-o4rc. C4
Installer's Name,Address,and Tel.No.SD9-4't7 y-19FS7"7 Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
,413"D ) J6Pz IC �S�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of H
Signed Date 13
Application Approved by Date 2 /— /
Application Disapproved by 0 Date
for the following reasons
Permit No. I 3 -o Date Issued f -t
d - Fee J
No.
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Ye
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0(ppYication for Misposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair( _) Upgrade( ) Abandon(A ❑Complete System ❑Individual Components
Location Address or Lot No. f75' GO, W cD-%> eq06 Owner's Name,Address,and Tel No.
NY C"is jAkkeS s 514AAON PH ZAd
Assessor's Map/Parcel Agg I I oo yd15 GLeX<OG AJE U-;V3 W1AWIUA145c, t C®
Installer's Name,Address,and Tel.No. $p8_qT7-IW$'Y'7 Designer's Name,Address,and Tel.No.
CA 1Pe,0I D E eajTZX d1SeS L-L-C N/A-
_ T
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
A 13AWDC 56PT t G
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in,
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of H
Signed Date. 3 'a I v I
Application Approved by Date
i.
Application Disapproved by Date
for the following reasons !
J
Permit No. Z 0 ( 3 -D 4 l Date Issued 7 - ' l
TH E COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
J--we Certificate of Compliance _
P THIS IS TO CERTIFY,that the On-site
Sewage
Sewa e Disposal system Constructed Repaired Upgraded(_
Abandoned(x)by cA0EwlDC GJj782pk(S& , )
UC
at—A!; GQsEy-Ls 0QP A J6 14\iA-") J1 S has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. D 0 1 -U�1pdated _Z -? / 3 .
Installer Cy(pEkAD6 607a XJ-< Ur- Designer
#bedrooms Approved design flow gpd
The issuance of this permit shall not be construed as a guarantee that the system will fun c'1ienlas designed. r
Date S r //? Inspector J/110' Aw
No. �� 1 I Fee 2
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
jBisposal 6p5tem Construction AErmit
Permission is hereby granted to Construct( ) Repair( ) Upgrade( ) Abandon(X)
System located at 175 G oGa)Lgo cx:>-r-) A U E NY A Q 01 5
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Cons ctionTust1 be completed within three years of the date of this permioi,
f
Date a ( Approved by
�pTHE T
Town of Barnstable Barnstable
Regulatory Services Department AS-Amedcacty
1 ► ;
BARNRrABLE,
.Ass.639- Public Health Division.
pTED MAID 200 Main Street, Hyannis MA 02601 2007 `
Office: 508-862-4644 Thomas F.GeilerLeach pit is only3f
)undwagter,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7006 1810 0000 3525 5231
May 2, 2011
Steven Young
15 Fred Smith Road
Westminster MA 01473
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system 75 Greenwood Ave,Hyannis,MA,was last inspected on 4/15/2011,
by David J. Burnie, a certified septic inspector for the State of Massachusetts.
• The se inspection of the septic stem showed that the system"Failed"under the guidelines
p P
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
Single cesspool automatically fails- Cesspool blocks are loose and unsafe.
Normally with a failed cesspool you would have 2 years to replace it with a Title 5 Septic
System. Because the cesspool has been found unsafe, you are ordered to repair or replace
the system within sixty(60) days from the date you receive this notification.
Failure to repair/replace the cesspool within the deadline period will result in future
enforcement action.
PE lB£ E BOA F HEALTH
T 'ma c can R 4 , CHO
Agent of the Board of Health
•
I
Q:\SEPTIC\Letters Septic Inspection Failures\1-1 SAMPLE 60 Day Deadline.doc
Mir P,
\o/t*19Twir�s� Commonwealth of Massachusetts
Titi-e 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75 Greenwood Ave tT
,Property Address ;.
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is Owner's Name
required for every
page. Hyannis Ma 02601 4-15-11
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. General Information
on the computer, ( j
use only the tab 1. Inspector:
key to move your
cursor-do not David J. Burnie
use the return Name of Inspector
key.
David J. Burnie Management, Inc -
my Company Name
3 Perry's Way ' =
Company Address
Harwich Ma. j 02645 •4 ,
Citylrown State y + Zip Code J "�
508432-0223 S1 386 I c. '
Telephone Number License Number
i,
i
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
4-15-11
Inspector's Sig a Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner.
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use .
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
U4
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ' 75 Greenwood Ave
Property Address
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is Owners Name
required for every
page. Hyannis Ma 02601 4-15-11
Cityrrown State Zip Code
Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
THE SYSTEM IS A FAILURE, THE CESSPOOL BLOCKS ARE LOOSE AND UNSAFE.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y , ❑ N ❑ ND (Explain below):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 75 Greenwood Ave
Property Address
Steven Young 15 Fred Smith Rd.Westminster Ma. 01473
Owner
information is Owner's Name
required for every
page. Hyannis Ma 02601 4-15-11
Cityrrown State Zip Code
Date of Inspection
B. Certification (cost.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y 0 N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
16.303(1)(b)that the system is not functioning in a manner which will protect public health,
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 75 Greenwood Ave
Property Address
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is Owners Name
required for every
page. Hyannis Ma 02601 4-15-11
City/Town State Zip Code
Date of Inspection
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
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply'well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but'50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for 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:
1
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.y svey`eW 75 Greenwood Ave _
Property Address
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is Owner's Name
required for every
page. Hyannis Ma 02601 4-15-11
Cityrrown State Zip Code
Date of Inspection
❑ ® 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
❑ Y® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
I
❑ ❑ the system is within 400 feet of a surface drinking water supply
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
75 Greenwood Ave
Property Address
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is Owners Name
required for every
page. Hyannis Ma 02601 4-15-11
Cityrrown State Zip Code
Date of Inspection
❑ ❑ 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.
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
E ❑ 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?
® El information
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)]
t5ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75 Greenwood Ave
Property Address
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is Owner's Name
required for every
page. Hyannis Ma 02601 4-15-11
Citylfown State Zip Code
Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): unknown Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): unknown
D. System Information
Description:
The system is a cesspool with a 2"d component that we were unable to find, we probed into stone
only, the homeowner refered to it as a drywell. The system is a failure because the blocks in the
cesspool have shifted and the cesspool is likely to collaps.
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)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Seasonal
Date
CommerciallIndustrial Flow Conditions:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 75 Greenwood Ave
Property Address
Steven Young 15 Fred Smith Rd.Westminster Ma. 01473
Owner
information is Owner s Name
required for every
page. Hyannis Ma 02601 4-15-11
Cityrrown State Zip Code
Date of Inspection
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:
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Never pumped per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M „ ' 75 Greenwood Ave J
Property Address
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is Owner's Name
required for every
page. Hyannis Ma 02601 4-15-11
City/Town State Zip Code
Date of Inspection
® 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):
Cesspool with drywell
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
Estimated consrtucted 1960 .
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 32"feet
Material of construction:
❑ cast iron ❑40 PVC ® other(explain): Orangeburg
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Old and worn
Septic Tank(locate on site plan):
Depth below grade: feet
µ
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments .
75 Greenwood Ave
Property Address
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is OwnePs Name
required for every
page. Hyannis Ma 02601 4-15-11
State Zip Code
Cityrrown Date of Inspection
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ®other(explain)
Block cesspool and drywell overflowl
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:
D. System Information (cont.)
Septic Tank(cont.)
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?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75 Greenwood Ave
Property Address
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is Owners Name
required for every
page. Hyannis Ma 02601 4-15-11
City/Town State Zip Code
Date of Inspection
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
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
r
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 75 Greenwood Ave
Property Address
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is Owner's Name
required for every
page. Hyannis Ma 02601 4-15-11
Cityrrown State Zip Code
Date of Inspection
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
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 75 Greenwood Ave
Property Address
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is Owner's Name
required for every
page. Hyannis Ma 02601 4-15-11
Cityrrown State Zip Code
Date of Inspection
Alarms in working order: ❑ Yes ❑ No
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:
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:,
® -overflow cesspool number: 1 + drywelf
❑ innovative/alternative system F
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of.
vegetation, etc.):
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
T ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M s ' 75-Greenwood Ave
Property Address
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is Owner's Name
required for every
page. Hyannis Ma 02601 4-15-11
Cityrrown State Zip Code
Date of Inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 1 cesspool dry
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool 6x6
Materials of construction
Indication of groundwater inflow ❑ Yes ® No
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 75 Greenwood Ave
Property Address
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is Owner's Name
required for every
page. Hyannis Ma 02601 4-15-11
Cityrrown State Zip Code
Date of Inspection
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 75 Greenwood Ave
Property Address
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is Owner's Name
required for every
page. Hyannis Ma 02601 4-15-11
City/Town State Zip Code
Date of Inspection
X
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water -
Check cellar
® Shallow wells
Estimated depth to high ground water: 8' plus
feet
Please indicate all methods used to determine the high ground water elevation:
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
• Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
75 Greenwood rd
Property Address
Steven Young 15 Fred Smith Rd.Westminster Ma. 01473
Owner
information is Owners Name
required for every
page. Hyannis Ma 02601 4-15-11
Cityrrown State Zip Code
Date of Inspection
A
D. System Information (cunt.)
Site Exam:
® Check Slope*
® Surface water
® Check cellar
® Shallow veils
Estimated depth to high ground water. 8'plus
feet
Please indicate all methods used to determine the high ground water elevation:
t5ins MOB Title 5 Official Inspection Form:Subsurface Sewage Disposed System•Page 16 of 17
M
Commonwealth of Massachusetts
• Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
75 Greenwood Ave
Property Address
Steven Young 15 Fred Smith Rd. Westminster Ma. 01473
Owner
information is Owner's Name
required for every
page. Hyannis Ma 02601 4-15-11
Citylrown State Zip Code
Date of Inspection
❑ 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:
Cesspool dry at time of inspection bottom of cesspool is 8' below grade.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
Inspection SummaryD (System Failure Criteria Applicable to All Systems)completed
® System'Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
1 "
Ft5ins•09108 Title 5 Official Inspection Form:Subsurfaoe Sewage Disposal System•Page 17 of 17