HomeMy WebLinkAbout0062 KELLEY ROAD - Health a ' T 62 Kelley Road
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TOWN OF B RNSTABLE
LOCATION 1pa SEWAGE# -
VILLAGE Hv AijAj), ASSESSOR'S MAP&PARCEL f ''
INSTALLERS NAME&PHONE NO. P
KM C,01A4rat,&r-J ?IT--
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) ,���� wtD t-� (size) ( I;,Ig Z"Y,
NO.OF BEDROOMS
OWNER Zakti Nl ek3,�Oe CKI f
PERMIT DATE: S/,Y'-o?OL3 COMPLIANCE DATE: - f
,Separation Distance Between the: \
P �
V'aximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Pribate Water Supply Well and Leaching Facility(If any wells exist
o site or within 200 feet of leaching facility) /� Feet
EdA of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) IV ll F et
FURNISHED BY pK/-I
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�� • Fee
No-r '
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
• Yes
PUBLIC.HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Zipplication for ]Bioogar *pgtent Congtruction vermit
Application for a Permit to Constrict( . )Repair(*Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot N�78/1 0 K.e`le Owner's Name,Address and Tel. 61.9 2
Assessor'sMap/Parcel 1� " �
�qZ 3 lq b LAQ1,011
Installer's Name,Address,and Tel.No. Des' er's Name,Addre s andjl.No.
CD/)T l GT1�,C S� �� 5- Gv� J6 V*-Atfow-
PD a0}l-175 .I FWN/.J M ,5-y93 Z0 3 s&7vea'f 12*4`0d-
Type of Building:
Dwelling No.of Bedrooms Lot Size yy0�¢sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons. Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 3 0 gallons per day. Calculated daily flow 6 G 0 gallons.
Plan Date -7 Z91 3 Number of sheets Revision Date
Title PRoboeL Il
Size of eptic Tank 56T� Type of S.A.S. 74.C• iN
Description of Soil; ddAkSr, 7 ,OLI'JV►S/ cfA-AQ
Nature of Repairs or Alterations(Answer when applicable)
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 t-to place the system in operation until a Certifi-
cate of Compliance has been i b oard f Heal
Sig Date 7 /�
_ Application Approved b _ Date5A'A
Application Disapproved fo a following reasons
Permit No. — Date Issued
No: w"../ µ Fee
Y Entered in computer:
THE�COMMONWEALTH OF-MASSACHUSETTS
p
PUBLIC HEALTH DIVISION TOWN,OF BARNSTABLES MASSACHUSETTS' Yes
tM1.d t i -ry1
of p g`t`ettt �ongtruction Permit 1pplication for Miopo 6
i
Application for a Pernut to Con ct( . )Repair(*Upgrade( �)Abandon( 9) O Complete System El Individual Components
Location Address or Lot N /� —Kir//e`/�G O`wnner's Name,Address and Tel.No.
^' Assessor's Map/Parcel a /
Z 9 Z 5 3 /9 sE� /ZGr4� SA 1
f
Installer's Name,Address,and Tel.No. 4tS�. Dest er's Name,Address and Tel.No.
10o A X 775 f.l FAIN/, 1W Z o 3 s c7U6a-7 / 00d-
Type of Building:
Dwelling No.of Bedrooms Lot Size �/��DU�sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( )'Cafeteria( )
"< -"Other Fixtures
Design Flow 3310 ;..__gallons per day. Calculated daily flow la G O gallons.
Plan Date o2U/3 Number of sheets Revision Date- —
Title PR0bPA62 (F-PI-71 Xf( AJ
Size of eptic Tank / ,`5!5b ! Type of S.A.S. 77? _&H � W,C. /N/:�.
Description of Sod; CDA.'SF DAB JA-x p ;
Nature of Repairs or Alterations(Answer when applicable) f
UA
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 of to place the system in operation until a Certifi-
rate of Compliance has been issued b s- oard f Health.
Sig / Date 5/
7 �/.3
Application Approved b} ✓ Dates /
Application Disapproved for le following reasons
Permit No. rr' � '� i Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
s ' ' BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ' )Repaired( X)Upgraded( )
Abandoned( )liy 11) CO&tOZA CID 2S / \
at (17- kEL 1 lh1as been constructe in a•cordance
with the provisions of Title 5 and the for Disposal System onstruction Permit No� '"-� :2 dated , / 3
Installer Designer /� ���
The issuance of this pe t s'h,21l t t C 9strued as a guarantee that the s t m w'll ul do as de 'netMlIn
I,Date T �I Inspector // /�
No.�` J � --.———. . ... Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mizpaal *pgtem Congtruction Perron
Permission is hereby granted to Construct( )Re air(�Upgrade'(' )Abandon( )
System located at K � �O 1�
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 cond'tions7this
a
Provided: Construction must Fie completed within three years of the ate ofSpe *tL. �
Date Approved b
j
• I
Town of Barnstable
Regulatory Services
c� Thomas F. Geiler,Director
t,AS&
Public Health Division
639. A�� Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 50812-4644 Fax: 508 790-6304
Date: �l " /2D� 3 Sewage Permit# 2��3—1 7 Assessor's Ma /Parcel
g P
Installer& Designer Certification Form
Designer: �''f� C��-�^���i'� Installer: ��Cyi"l �*,.JT2rkT02 S� ✓
Address: Z�3 ��✓-Tvc K��XP Address: /,e°< 77S
On 7ZI�4 ZOI �����^��' c1�.cf was issued a permit to install a
(date) � (installer))
septic system at Z 1<CC!,Cey / //r" based on a design drawn by
(address)
dated 2 7 e/ 3
/ (designer)
v I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Stripout (if required i spected and the soils
were found satisfactory. st+of P/,as,
TERENCE
a
(Installer's ur) " HAYEE cn
No. 979 a
FGlcTcF
SAAlITAR\��
na
(Designer's igna (Affix Designers Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
gAoffice fortes\designercertification form.doc
a9a -0�3
Commonwealth of Massachusetts
Title 5 official Inspection Fora Ny;
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments p
/1 6•�
62 Kelley Road
1
Property Address ,
Daniel Jordan
cKr
Owner Owner's Name ?
information is Hyannis Ma 02601 6-19-19
required for every y
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 6�on the computer,
use only the tab Brett Hickey
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key.
374 Route 130
crs Company Address
Sandwich Ma 02563
City/Town State Zip Code
rznro (508)477-0653 S113747
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. 0 Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Brett Hickey �° """"�'��" 6-19-19
;.�:m.�„mow.a...��,��.�s,,,.�,.�.�.�
•'Oma:3018.OB.Z008:S9:51 M}p
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
r
Commonwealth of Massachusetts
�s Title 5 official Inspection dorm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Kelley Road
v
Property Address
Daniel Jordan
Owner Owner's Name
information is Hyannis Ma 02601• 6-19-19
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes;
❑� I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system was in working order at the time of inspection.
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.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Kelley Road
V�
Property Address
Daniel Jordan
Owner Owner's Name
information is Hyannis • Ma 02601 6-19-19
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ 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):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if -
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form .
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t
62 Kelley Road
Property Address "
Daniel Jordan
Owner Owners Name'
information is H annis Ma 02601 6-19-19
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Suinmary (cont.)
❑ Cesspool or privy is witin 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
t more from a private water supp4 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 tliat no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other: j
i
r
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
ry 1
Yes No
❑ O Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool .
❑ a 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.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
a i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
k % 62 Kelley Road
Property Address
Daniel Jordan
Owner Owner's Name
information is Hyannis Ma 02601 6-19-19
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ a Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
❑ El 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 SAS, cesspool or privy is below high ground water elevation.
❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El El well.
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.
❑ El 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.]
❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ a 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 Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Kelley Road
v Property Address
Daniel Jordan
Owner ' Owner's Name
information is + Ma 02601 6-19-19
Hyannis ,
required for every y
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 '
El, ❑ Pumping information was provided by the owner, occupant,'or Board of Health
7. ❑ ❑ r Were any of the system components pumped out in the previous two weeks?
' 0 ❑ Has the system received normal flows in the previous two week period?
El E 'i Have large volumes of water been introduced to the system recently or as part of
this inspection?
El ElWere as built plans of the system obtained and examined?.(If they were not
available note as N/A)
1 ❑ ❑ Was the facility or dwelling inspected for signs of sewage back up?
.I . El .❑ Was the site inspected for signs of break out?
0 ❑ Were all system components, excluding the SAS, located on site?
r El ❑ ' ` 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:
E ❑ 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.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
i
Commonwealth of Massachusetts
�o Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
62 Kelley Road
Property Address
Daniel Jordan
Owner Owner's Name
information is required for every -Hyannis annis Ma 02601 6-19-19
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
3 3
Number of bedrooms (design): Number of bedrooms (actual):
330/GPD
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description: ,
Number of current residents:
i
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes Q No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes 0 No
Seasonal use? ❑ Yes 0 No
See below
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
***2017- 10,2000gallons 2018- 8,700gallons***
Sump pump? ❑ Yes ❑■ No
Last date of occupancy: current
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 ,
Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments f
62 Kelley Road
Property Address
Daniel Jordan
Owner Owner's Name
information is Hyannis Ma 02601 6-19-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
NA
Type of Establishment:
Design flow(based on 310 CMR 15.203): .
Gallons per day(gpd)
Basis of design flow(seats/personsisq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
i
3. Pumping Records:
Owner- last pumped 4 years ago
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
t
1
Commonwealth of Massachusetts
�e Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.v
62 Kelley Road
Property Address
Daniel Jordan
Owner Owner's Name
information is Hyannis Ma 02601 6-19-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
El Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and ,
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ . Other(describe):
Approximate age of all components, date installed (if known) and source of information:
2013 per plans
Were sewage odors detected when arriving at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan):
2811
Depth below grade: feet
Material of construction:
❑ cast iron ❑■ 40 PVC ❑other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
I
t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of (Massachusetts
Title 5' official Inspection Form
• Subsurface Sewage Disposal System Form Not for Voluntary Assessments
62 Kelley Road " It
Property Address
Daniel Jordan ,
Owner. Owner's Name
information is required for every -Hyannis annis Ma 02601 6-19-19
page. City/Town „ State Zip Code Date of Inspection
D. System Information (cont.) _
6. Septic Tank(locate on site plan):,,
16
" Depth below grade:,
- : feet
Material of construction: I
9 concrete ❑ metal �� ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
' years '
Is age confirmed by a Certificate of•:,ompliance?(attach a copy of certificate) ❑ Yes ,[ No
1500gallons
Dimensions: ` 1i
6,�
Sludge depth: "
n 30,•
` { Distance from top of sludge to bottom of outlet tee o'r baffle
Scum thickness u 3�+
Distance from top of scum to top of outlet tee or baffle .
13
Distance from bottom of scum to bottom of outlet tee or baffle +
measured
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.):
The tank was in working order at the time of inspection. The tank was pumped
after inspection for maintenance. ,
. 1
t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
I €
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,w 62 Kelley Road
Property Address
Daniel Jordan
Owner Owner's Name
information is Hyannis Ma 02601 6-19-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: NAfeet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: NA
Material of construction:
I
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
i
J
Commonwealth of Massachusetts
�a Title 5 Official Inspection Form_
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Kelley Road
Property Address +;
Daniel Jordan
Owner Owner's Name
information is Hyannis Ma 02601 6-19-19
required for every y I
page. City/Town y State Zip Code Date of Inspection -
®. System Information '(cont.) -
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No .
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping(contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):,
r .
orr
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.):
The d-box was in working order at the time of inspection.
i
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
d Title 5 Official Inspecti®r� Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Kelley Road
Property Address
Daniel Jordan
Owner Owner's Name
information is Hyannis Ma 02601 6-19-19
required for every y
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.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type: t
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
11'X36'X10"
leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
l5insp.doc•rev.7262018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
u
c Commonwealth of Massachusetts
�d Title 5 official Inspection Form
ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Kelley Road
Property Address
Daniel Jordan
Owner Owners Name
information is Hyannis Ma 02601 6-19-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was in working order at the time of inspection. Leaching was dry when viewed
with no evidence of past back up.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil;; signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official' inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
62 Kelley Road
Property Address
Daniel Jordan
Owner Owner's Name
information is Hyannis Ma 62601 6-19-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
NA
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
vv62 Kelley Road
Property Address
Daniel Jordan
Owner Owner's Name
information is Hyannis Ma 02601 6-19-19
required for every y
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
i
the building. Check one of the boxes below:
j ■❑ hand-sketch in the area below
❑ drawing attached separately
LC7CATTg1�1 b 1 y £f ^� _ S'E•WAOF.
t a V2LLAC3E : }S ASSESSQR.'.5 MAP&PARCEL
INSTALLERS N A'ME @:PF'1ONE tJO — t.
S.e4llw
S2rP 1'1C TANK C:l:PACTTS'
i w - ---
t LEACFING FAOiT:.ITy;(type) R 4•-L-14 ,Jkzst`_S;- (size)—IA-.)_2,�%.'+'t
No.OF Btbio0MS
a t OYWNEIZ'. �C1l+L� + �2�1���2:C�{�.---------
PERMIT DATE . _L 6L3Z COMPL'iANCE DATE;
Separalttin%`I3istiuice Between the.
Maximum-Adjusted Crrotindwatcr;Table to the Booms of Lt-whing Finality.. _.
Private water Supply Well-afl Leaching Facility(rfany we11s exist,
on site in within'260 fcet:oflearhing fneitity) NA
Edge of W.t:iLu d and Leaching Ficuity.(if sny wetlands exist
vnthyn 300 fccs itf leaching facility) _ ,.:.T�cet
rL'1RNiSHi By.°��. a J '
- n
t r $
o7L!`0
i 'r a j 34 -�4 t'
t5insp.doe-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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Kelley Road
Property Address
Daniel Jordan
Owner Owner's Name
information is Hyannis Ma 02601 6-19-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
■❑ Check Slope
❑N Surface water
❑■ Check cellar
■❑ Shallow wells
Estimated depth to high ground water: No GW 4' below SASfeet
- Please indicate all methods used to determine the high ground water elevation:
El Obtained from system design plans on record
5-14-13
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS) ,
f ❑ 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:
A plan on file at the local Board of Health was used to determine high groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
1
Commonwealth of Massachusetts
, . Title 5 Official Inspection Form '
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
62 Kelley Road
v Property Address
Daniel Jordan Il
Owner Owner's Name F .
information is= Hyannis - Ma 02601 6-19-19
required for every
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.
• f q ,
■❑ 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
MR D. System Information:, a' i
For 8: Tight/Holding Tank-Pumping contract attached
For 14: Sketcli of Sewage Disposal System drawn on,pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
� I
ii
t5insp.doc-rev.7262018 N Title 5 Official Inspection Form:Subsurface Sewage Disposal System'Page 18 of 18
t ,
Town of Barnstable . P# y
T
Department of Regulatory Services
Public Health Division Date /✓
NAM
�h¢ 200 Main Street,Hymnis MA 02601
Date Scheduled' // �/ Time < Fee Pd. O
{
Soil Suitab►iiiV,, Assessment for S �. --'- Disposal
�. :..Performed By: / �� i O� WitnessedAWN
By:
Location"Address r1 . ; btu( Owner`sName:t `lift NGIdzICJC'C6.
4000 Sands4Dnt: 'D.r-
Address
co lleie, �-�9+c v"6�TX 7 7d lid
`5
/.
Assessor'sMap/Paicel: Ot qQ S3 Engineer's Name wEZ°r :5CR EN61AjC_P) 6
.
W•fill! -C 0 le
NEW CONSTRU CiTION REPAIR Te eepbone# p U
Land USo av
pas(/o) Unn surface stones
Distances from: Open Water Body ft Possible Wet Area N/r ft Drinking Water Well N 1.1 ft
Dtainage Way ft Property Line 7 ( ft Other N ft
SKETCH:(Street name dimensions of lot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
i
LOh
tJ
k z
C0f77 �o
cn
Parent material(geolp ic) v T � Depth to Bedrock
a / /
Depth.to Groundwater. Standing Water in Hole: �/ � Weeping from Pit Face
Estimated Seasonal High Groundwater
t ".b
Method Used: O ��'`L[J�-TIL.✓
Depth Otisorved standitig in.oba..hdle: in. Depth to soil mottles: in.
Depth to%Ve ping from side of obs.hole: is Oro�dwater Adjustment ft
Index Wcll# Rcading,Datc: -. Index.Well.ledel Adj.factor Adj.Groundwater Level_
.
Observation Y
Hole# " Time at 9"
Depth of Perc {' Time at 6"
Start Pre-soak Time® Ga Titme(9"-6-)
End Presoak
Rate Min./Incb
Site Suitability Assessment: Site Passed . f Site Failed: Additional Testing Needed(Y"
Originals Public Health,Division Observation Hole Data To Be Completed on Back------
***If percolad Q'�n test is tube conducted•within 1�:00'of wetland,you must-first notify the
Barnstable Co>d>er adon;DWdou at least one fl)week prior to.beenning.
Q:4SEPTI0PERCFO4M.DOC
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