HomeMy WebLinkAbout0044 HOMEPORT DRIVE - Health 44 ROMEPORT DRIVE, HYANNIS
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Commonwealth of Massachusetts
J�= Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Homeport Drive
Property Address
Evan Howe
Owner Owner's Name
information is
required for every Hyannis MA 02601 5-3-2021
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 only the tab Carmen E. Shay
key to move your Name of Inspector
cursor-do not Shay Environemntal Services
use the return Company Name
key.
PO Box 1576
r� Company Address
Mashpee MA 02649
Citylrown State Zip Code
508-294-7498 _ 3080
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
5-3-2021
Inspector's Signa ure Date
The system inspector shall submit opy 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
;b 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.
t
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
J Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c� >I
44 Homeport Drive
Property Address
Evan Howe
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-2021
page. Citylfown 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:
Syste consists of a 1500 gallon tank, Dbox and a 3 INFILTRATOR Chambers With 4' Stone all
around
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
. Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
\ � 44 Homeport Drive
v
Property Address
Evan Howe
Owner Owner's Name
information is Hyannis MA 02601 5-3-2021
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
a
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
ipumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ 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 FIND (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
i
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:
n
{ t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
4
Commonwealth of Massachusetts
�r l Title 5 Official Inspection Form
i,
Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments
44 Homeport Drive
Property Address
Evan Howe
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
,
c. Other:
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' 4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.'7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Homeport Drive
Property Address
Evan Howe
Owner Owner's Name
information is required for every y H annis MA 02601 5-3-2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure.Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an cverloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) ,Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
I'] Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Homeport Drive
u-
Property Address
Evan Howe
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no" for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
'° wJ Subsurface Sewage Disposal System Form Not for Voluntary Assessments
44 Homeport Drive
V
Property Address
Evan Howe
a
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-2021
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
System consists of a 1500 gallon tank, Dbox and 3 INFILTRATOR Chambers with 4' stone all around.
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
2018-113,000 2019-123,000
Sump pump? ❑ Yes ❑ No
E Last date of occupancy: Date
:v
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
•t'4
r
Commonwealth of Massachusetts
�p Title 5 Official Inspection Form
h Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/�
44 Homeport Drive
v
Property Address
Evan Howe
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) e
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
t Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
1
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 e
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
Howwas quantity pumped determined?
Reason for pumping:
e
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� iI Subsurface Sewage Disposal System Form Not for Voluntary Assessments
44 Homeport Drive
V�
Property Address
Evan Howe
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system a
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1998 per records on file with the health department
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Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
5. Building Sewer(locate on site plan):
Depth below grade: 1' 6"
feet
Material of construction.-
El cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 20
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
A
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' t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
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Commonwealth of Massachusetts
�r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
...... 44 Homeport Drive
v—
Property Address
Evan Howe
Owner Owner's Name
information is Hyannis MA 02601 5-3-2021
required for every H y �
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 6 inches
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) e
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 5x5x10—
Sludge depth: 6
Distance from top of sludge to bottom of outlet tee or baffle
23"
Scum thickness 1/2
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
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How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank in good condition. Inlet and Outlet Tee in good condition. No evidence of backup or infiltration
or exfiltration.
t5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c
Commonwealth of Massachusetts
-,�7p Title 5 Official Inspection Form
w .Subsurface Sewage Disposal System Form Not for Voluntary Assessments
44 Homeport Drive
Property Address
Evan Howe
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
m
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, structura! integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction.-
El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/M18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 o'18
1
Commonwealth of Massachusetts
�i ,lp Title 5 Official Inspection Form
11 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
10 44 Homeport Drive
v
Property Address
Evan Howe
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
e
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert D-Box Present
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.):
1 outlet equal with outlet invert. No Evidence of carryover. NO backup noted.
M
t5insp.doc•rev.7/2 6120 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v-
44 Homeport Drive
Property Address
Evan Howe
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order:. ❑ Yes ❑ No`
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
e
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length:
11x30x2
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
e
❑ 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
I
Commonwealth of Massachusetts
1= Title 5 Official Inspection Form
i
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Homeport Drive
V�
Property Address
Evan Howe
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-2021
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of e'
vegetation, etc.):
Probed area and Found no evidence of backup noted. Probed stone around SAS and found no
evidence of hydraulic failure. Leach Trench is operating properly. 3-Infiltrator Chambers present
with 4 feet stone all around.
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
e
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
' e
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
(101
Commonwealth of Massachusetts
P Title 5 Official Inspection Fora'
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Homeport Drive
Property Address
Evan Howe
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-2021
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
�I Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
e
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
I
k
Commonwealth of Massachusetts
Title 5 Official Inspection Form
AI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Homeport Drive
u�
Property Address
Evan Howe
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-2021
_
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
A
A
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Homeport Drive
t.-
Property Address e
Evan Howe
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
f
Check cellar
® Shallow wells
Estimated depth
121+
p to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
e
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:
Bottom of SAS is 5 feet below Grade. Hand augered to 12 feet with no water encountered.
MIW29-Zone C 3.5' Adjustment for April 2021. Bottom of SAS is 5 feet. System is out of Adjustment.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15insp.doc•rev.7/26/2018 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 or 18
Commonwealth of Massachusetts
I�F Title 5 Official Inspection Form
�['I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
44 Homeport Drive
of Property Address
Evan Howe
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-2021
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 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
d ,
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
2,11412020 Assessing As-Built Cards
TOWN OF BARNSTABLE
LOCATION 0!1:� SEWAGE#
V11,1LAGE-,5�4.d Zy- r74 4 i ASSESSOR'S MM&LOT
INSTALLER'S NAME&PHONE NO. ilt^ t e 2,5-,? ?7
SEPTIC TANK CAPACITY
LEACHING FACII_ITY;(type) —/VP-n 3 (size*)
NO.OF BEDROOMS I
BUILDER OR OWNER 0
PERMlTDATE:_Fe-/:Z- T COMPLIANCE DATE:
Separation Distance Between the:
Ntiximurn Adjusted GroundwalcrTable to the Bottom of LoQhngl Facility s Feet
Nivate Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 fee of leaching facility) / Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts
Title 5 Official Inspection Form COQ
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
y� 44 Homeport Drive,West Hyannisport, MA
Property Address
Stingel Family Irrevocable Trust, Tammy Jordan'trust
Owner Owner's Name
information is Hurley required for y NY 12443 December 12,2011
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When fllling out A. General Information
I
forms on the I,,
omputer,use
lly the tab key 1. 1nSpeCtoi:
to move your David B. Mason
cursor-do not Name of Inspector
use the return
key. David B. Mason
Company Name
4 Glacier Path
Company Address
Fast- andwich MA 42537
City/Town State Zip Code
508-367-1617 S 1287
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`s
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 `11
4
❑ Needs Further Evaluation by the Local Approving Authority
N?
December 12,2011
Inspectors Signa r Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or MP)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.
tSlns•1 t/10 The 5 Official Inspection Form:Subsurface Sewage Dispose ter•Page 1 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
44 Home port Drive,West H annis ort, MA
Property Address
Stingel Family Irrevocable Trust,Tammy Jordan Trust
Owner Owner's Name
information is required for Hurley NY 12443 December 12,2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
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:
This inspection information represents the condition of the system on December 12, 2011 at 8:00 AM
and only that date and time nor does the inspection guarentee the future operation of the system
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 exfltration 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•11f10 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Homeport Drive, West Hyannisport, MA
Property Address
Stin el Family Irrevocable Trust,Tammy Jordan Trust
Owner Owner's Name
Information is Hurley required for Y NY 12443 December 12,2011
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
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):
El obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
Wns-11110 Tide 5 Official Inspection Form:Subsurface Sewage Otsposel System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
5
g 44 Homeport Drive,West Hyannisport, MA
Property Address
Stingel Family Irrevocable Trust,Tammy Jordan Trust
Owner Owner's name
information Is Hurley
required for Y NY 12443 December 12, 2011
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Metb od-used-to-detemi ne-d ist-anee:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all Inspections:
Yes No
® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
Mrs-1 ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Homeport Drive,West Hyannisport, MA
Property Address
Stingel Family Irrevocable Trust,Tammy Jordan Trust
Owner Owner's Name
information Is Hurley
required for Y NY 12443 December 12,2011
every page. CItyrrown State Zip Code Date of Inspection
B. Certification (cunt.)
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 facillity 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 Iis considered a significant threat,
or answered"yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins.11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 or 17
N Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Homeport Drive,West Hyannisport, MA
Property Address
Stingel Family Irrevocable Trust,Tammy Jordan Trust
Owner Owner's Name
information is required for Hurley NY 12443 _December 12, 2011
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate ayes"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?
to. ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered,opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Wins•11110 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
44 Homeport Drive,West Hyannisport, MA _
Property Address
Stingel Family Irrevocable Trust,Tammy Jordan Trust
Owner Owner's Name
information is
required for Hurley NY 12443 December 12, 2011
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Assessors records indicate 4 bedrooms, system design and asbuilt card indicate 3 bedrooms.
System sizing is not a passing nor failing criteria.
Number of current residents: Seasonal
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?jif 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:
2011 is 5250 gallons and 2010 is 3750 gallons.
Sump pump? ❑ Yes ® No
Last date of occupancy: Summer 2011
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins 11/10 Title 5 Otficlal Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Homeport Drive,West Hyannisport MA
Property Address
Stingel Family Irrevocable Trust,Tammy Jordan Trust
Owner Owner's Name
information is Hurley
required for NY 12443 December 12, 2011
_
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
i
General Information
Pumping Records:
Source of information: BOH
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 17
Commonwealth of Massachusetts
Title 5 official 'Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 44 Homeport Drive,West Hyannisport, MA
Property Address
Stingel Family Irrevocable Trust,Tammy Jordan Trust
Owner Owner's Name
information is Hurley required for y NY 12443 December 12,2011
every page. City/Town State Zip Code Date of Inspection
D. System Information cont.)
Approximate age of all components, date installed(if known)and source of information:
September 14, 1998
Were sewage odors detected when arriving at the site? ❑ Yes ® No
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: NA
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Appears in good condition
Septic Tank(locate on site plan):
Depth below grade: 15 Inches
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gallon tank measurements
Sludge depth:
2"
t5ins•11110 Tice 5 Official lnspedon Form:Subsurface Sewage Disposal System-Page 9 or 17
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Homeport Drive,West H annisport, MA
Property Address
Stingel Family Irrevocable Trust,Tammy Jordan Trust
Owner Owner's Name
information is Hurley required for y NY 12443 December 12, 2011
every page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 3811
Scum thickness oil
Distance from top of scum to top of outlet tee or baffle 41'
il
Distance from bottom of scum to bottom of outlet tee or baffle 0
How were dimensions determined? observation
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
PVC tees in good condition. Effluent level is level with outlet invert
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
t5lns•11110 Me 5 Official Inspecton Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Ti Sewage-tle 5Official Inspection Fora
Susurface Disposal System Form - Not for Voluntary Assessments
44 Homeport Drive, West Hyannisport, MA _
Property Address
Stin el Family Irrevocable Trust,Tammy Jordan Trust
Owner Owner's Name
information is Hurley required for y NY 12443 December 12, 2011
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
ISlns•11/1 0 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Homeport Drive,West Hyannisport, MA
Property Address
Stingel Family Irrevocable Trust,Tammy Jordan Trust
Owner Owner's Name
information is Hurley required for y NY 12443 December 12, 2011
every page. CItyfrown state Zip Code Date of Inspection
D. System Information (coat.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert Level with 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.):
Good condition. Dbox is 22 inches below grade. No indication of solids carryover.
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.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
SAS located. No access to plastic units. Probed stone area and no indication of
t5ins•11110 Title 5 Offidel Inspection Form:Subsurface Sewage DEsposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
5 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
V
44 Homeport Drive,West Hyanni'sport MA
Property Address -'
Stin el Family Irrevocable Trust,Tammy Jordan Trust
Owner Owner's Name
information is
required for Hurley NY 12443 December 12, 2011
every page. City/Town State Zip Code Date of Inspection
D. System Informations (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ leaching galleries number:
leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation, etc.):
No ponding or damp soil that would indicate hydraulic failure. No exessive growth of vegetation. SAS
is three(3)H2O Infiltrators with 4 feet of stone.
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
15ins-11I10 Tltle 5 Offlolal Inspection Form:Subsurface Sewage Disposal System Page 13 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Fora
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Home port Drive,West H annis ort, MA
_ P Y P
Property Address
Stingel Family Irrevocable Trust,Tammy Jordan Trust
Owner Owners Name
Information Is Hurley required for y NY 12443 December 12, 2011
every page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11110 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Homeport Drive,West Hyannisport, MA
Property Address
Stingel Family Irrevocable Trust,Tammy Jordan Trust
Owner Owner's Name
Information is required for Hurley NY 12443 December 12, 2011
,
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t JA5
6
7
..
t5lns•11/10 Tille 5 official lnspecllon 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
44 Homeport Drive,West Hyann'isport, MA
Property Address
Stingel Family Irrevocable Trust Tammy Jordan Trust
Owner Owner's Name
Information Is Hurley required for y NY 12443 December 12, 2011
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20
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:
Ground water contour map
® Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
gourndwater contour map and septic designs in the area
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11110 Title 5 Official Ins pectlon Form:Subsurface Sewage Dlsposa,System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�< 44 Homeport Drive, West H_yannisport, MA
Property Address
Stingel Family Irrevocable Trust,Tammy Jordan Trust
Owner Owner's Name
information is Hurley required for y NY 12443 December 12, 2011
every-page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Z inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page.15 or attached in separate file
t5ins•11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 117 of 17
�^ • TOWN OF BARNSTABLE
LOCATION Oa ' SEWAGE # a�
VILLAGE $ I ASSESSOR'S MAP &_LOT
INSTALLER'S NAME&PHONE NO. l 6,6 r w..;a I7 '�,S•��'�'�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) 2:,a ',^' sd-1� 3 (size) ^�od-
NO.OF.BEDROOMS
BUILDER OR OWNER � !
PERMTTDATE: �"O `� COMPLIANCE DATE: 9
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and-Leaching Facility (If any wells exist
on site or within,200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
- -.
� �.
(� � ,
, � -
I ! �; o� �
� �
� � �=
-�-----�;f � -
s
b
.�
4
t,
_ .
No. - Fee$5 t
i
'll
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIpplication for Mfi5po.5al bpgtem Cottgtruction Vermit
Application for a Permit to Construct( )Repair(x>0 Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. 44 Homeport Drive Owner's Name,Address and Tel.No. Henry Stingel
Assessor'sMap/Parcel W Hyannisport 347 Joys Lane Hurley, NY 12443
914 338-7739
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Septic Service
P O Box 1089, Centerville IAA 0263
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder(no)
Other Type of Building No.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 sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic System consisting
of 1500g tank, D—box, and three H-20 infiltrators.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b is)iroard of Hgqlth.Signed �i , j `�� DateJ�iS
Application Approved by Date S7 [of
Application Disapproved for th ollow g reasons
Permit No. Date Issued
*&
No.
'r V Fee$50 0 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ��/
PUBLIC HEALTH DIVISION - TOWN O -BARNSTABLE., MASSACHUSETTS Yes
F�
01pplication for �ioonl *p.5tem Construction Permit
Application for a Permit to Construct Repair(x*Upgrade Abandon El Complete System El Individual Components
Location Address or Lot No Owner's 44 Homeport Drive Owner's Name,Address and Tel.No. Henry Stingel
4Assessor's Map/Parcel W Hyannispott 347 Joys Lane Hurley, NY 12443
(914) 338-7739
Installer's Name,Address,and Tel.No. 7 7 5-8 7 7 6 Designer's Name,Address and Tel.No.
- W E Robinson Septic Service
P 0 Box 1089, Centerville MA 0263�
'Type of Building:
Dwelling No.of Bedrooms 3
Lot Size_sq.ft. Garbage Grinder(no)
Other Type of Building No.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 --L-Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic System consisting
of 1500g tank, D-box, and three H-20 infiltrators.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued y this. oard of He filth.
Signed I ol L7 Date
Application Approved by K:lg 04 4, - Date J!j-
Application Disapproved for th vollo-w49 reasons
Permit No. s-,a Date Issued
THE C6"M6 4MMONWFALTH OF MASSACHUSETTS
Stingel LPL• MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed Repaired (Xx)Upgraded
Abandoned( )by
at 44 Homeport Srive W Hyannisport has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer-W E Rtbinson peptic Ser**ce Designer
The issuance of this permit shall not be construed as a guarantee that the systenkwill function as designed.
Date CP I , , r d Inspector
No. s< Fee $50.00
W
THE COMMONWEALTH OF MASSACHUSETTS /0
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 3
-
Sting&& Im
Mi5po5al *P!9tem Con5truction Permit
Permission is hereby granted to Construct( )Repair(X:j Upgrade Abandon
System located at 44 Homeport Drive
W Hyannisport
Installer W E Robinson Septic Service
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:Construction must be completed within three years of the date of this permit.
Date: R - I Approved by
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, William E. Robinson. Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at. 44 Homeport Drive,West Hyannisport meets all of the
following criteria:
* There are no wetlands within 100 feet of the proposed leaching facility.
* There are no private wells within 150 feet of the proposed septic system.
* There is no increase in flow and/or change in use proposed.
* There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) _
B)Observed Groundwater Table Evaluation(according to Health Division well map) _
SIGNED:
�' DATE
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 20-1998
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
F
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COMMONWEALTH OF MASSACHUSETTS t �'' -. \� 0
7 EXECUTIVE OFFICE OF ENVIRONMENTAL AFF ItFS
�i DEPARTMENT OF ENVIRONMENTAL PRO TIONRR�NfO �
ONE WINTER STREET. BOSTON. MA 02105 617-292-»0 /�I/
To" 2 5 1 199 �a
• 't �
s�•` f/ Op
W1LLlAM F.WELD / T CIDY COXE
Governor ✓ . ecretary
ARGEO PAUL CELLUCCI D B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
4.4 Homeport Drive CERTIFICATION
Property Address- W Hya is rt MA Henry Stingel
t� Address of Owner: 3/�,7 Joys Lane
Date of Inspectiorr. 7'-��,�/ (If different)
Name of Inspector: WIri E Robinson Sr Hurley NY 124.43
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: WM E Robinson Septic Service
Mailing Address: PO Box 1 089, Centervi 1 1 p , MA 02632
Telephone Numbers 5 0 8 ;• 7 7 5—R 7 7 6
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
' Passes
— Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: d Date: --�-- /
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D: I
-11
i:K.criteria
ound any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
not evaluated are indicated below.
COMMENTS:
B) SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain.why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:/twww.magnet.state.ma.us/dep
Z�J Printed on Recycled Paper
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I � t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
P►FIrty�Address: 1' 4 Homeport Dr, W Hyannisport
Owner: Stingel
Date of Inspection:
�B):SYSTEM-CONDITIONALLY PASSES (continued)
a
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Condjj't'ions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
publ t health, safety and the environment.
1) ' SY EM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
ICH WILL PROTECT THE PUBLIC HEALTH AND 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.
i 2) S TEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
T E SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
EN IRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (approximation not valid).
3) O HER
(revised 04/25/97) Page 2 of 10
o �
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
44 Homeport Dr, W Hyannispott
Owner: St�gel�
Date of Inspection: /
D SYSTEM FAILS:
You ust idi ncate ei;!;er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
e
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) GE SYSTEM FAILS:
Yo must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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)
The own r or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirem nts of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) ?age 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
'CHECKLIST
44 Homeport Dr, W Hyannisport e w r
Property Address: Stingel
Owner: ! j
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
All system components, excluding the Soil Absorption System, have been located on the site.
✓ _ The septic tank manholes were uncovered, opened, and the interior,of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
-The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
s
(revived 04/25/97) Page 4 of 10
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4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 44 Homeport Dr, .W Hyannisport
Owner: S t inge 1
Date of Inspection:9_/�-��
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 96�O .p.d./bedroorn for S.A.S.
Number of bedrooms:
Number of current residents:0
Garbage grinder (yes or no): 4, d
Laundry connected to system (yes or no):V L 5
Seasonal use (yes or no):-yKS �— 7/96 - 7/97 54109cu ft 115, 500gais
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no): � 6 7797 — 7796 1500 cu 1 , 250gals
Last date of occupancy: �—
COMA4ERCIAUI NDUSTRIAL•
Type of a tablishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanit ry waste discharged to the Title 5 system: (yes or no)_
Water m I
ter readings, if available:
Last dat of occupancy:
OTH : (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no),Lli
If yes, volume pumped: gallons
Reason for pumping:
TYPE 0 SYSTEM
t Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: `l $
n
V
Sewage odors detected when arriving at the site: (yes or no)
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Homeport Dr, W Hyannisport
Owner: S tin
Date of Inspection:
BUIL ING SEWER:
(Locate n site plan)
Depth bel w grade:
Material o construction: _cast iron _40 PVC_other (explain)
Distan from private water supply well or suction line
Diamete
Commen s: condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:_
(locate on Site plan)
1
Depth below grade:
Material of construction: —concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
�✓ i �
Dimensions: C'
Sludge depth:_
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 0 .
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 dimensions were determined: ✓
Comments:
(recommendation for pumping, condition of Inlet and outlet tees or baffles depth of liquid level in relation to outlet invert, stru ural .
integrity, evidence of leakage, etc.) � � l �' �"' t^' C t'�
GREASE T P:
(locate on s e plan)
Depth belo grade:
Material of nstruction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimension
Scum thic ness:
Distance fro top of scum to top of outlet tee or baffle:
Distance fro bottom of scum to bottom of outlet tee or baffle:
Date of last p mping:
Comments:
(recommenda on for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, ev' ence of leakage, etc.)
(revised 04/25/97) Page 6 of 10 _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Homeport Dr, W Hyannisport
Owner: S nge 1
Date of Inspection: "l�
TI TOR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate n site plan)
Depth low grade:
Material f construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
Dimensi ns:
Capaci gallons
Design ow: gallons/day
Alarm le I: Alarm in working order Yes; _ No
Date of pr vious pumping:
Comments
(condition f inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_V
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note;it;level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.)w
r
a..
i
PUMP C AMBER:_
(locate on site plan)
Pumps i working order: (Yes or No)
Alarm in working order (Yes or No)
Comme ts:
(note co dition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Homeport Dr, W Hyannisport c
Owner: S�t inge l
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): !/
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:,
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative system:
Name of Technology:
JV Vt
Comments: ]
(note condit1i of soil, signs of hydrauli�failure,Avel of pf riding/condition of vegetation, etc.) ;,�
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comme ts:
(note co dition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
01
PRIVY:_
(locate n site plan)
Materia of construction: Dimensions:
Depth f solids:
Comm nts:
(note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/97) r Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Homeport Dr, W Hyannisport
Owner: S t in e 1
Date of Inspection: 9_1 9
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
3 w
s—
< W `
(revised 04/25/97) Page 9 of 10
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V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Homeport Dr, W Hyannisport
Owner: S.inge l
Date of Inspection:y
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from n o Design Plans o record
g
Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
P
Check pumping records
Check local excavators, installers
Use USGS Data
Des ibe in fur o wgrds how you established the High Groundwater Elevation. Must be completed)
(revised 04/25/97) Page 10 of 10
S
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TOWN OF BARNSTABLE _
LOCATION /!Z SEWAGE # o�
VILLAGE- + d iy i ASSESSOR'S MAP & LOT:2/4S_1. -h e-
i
INSTALLER'S NAE&PHONE NO. 1 6
SEPTIC TANK CAPACITY /J F ty
LEACHING FACILITY: (type) S—�Tc� ��',��►aS (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE: d�-
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) '"' Feet
Furnished by
i