HomeMy WebLinkAbout0110 KELLEY ROAD - Health 110 Kelley Roatl
d2 'Hyannis
A = 292 �058
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c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
" 110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owner's Name,
information is required for every yann His ✓ Ma 02601 3/23/2021
. .
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 A. Inspector Information 61*
filling out forms
on the computer, Chad Hathaway
use only the tab
key to move your Name of Inspector
cursor-do not Hathaway Septic Inspections
use the return Company Name
key.
� Company Address
Forestdale Ma 02644
Cityrrown State Zip Code
774 274 2581 12866
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
3/23/2021
cto s ign Date
The system inspector shall s it a py of this inspection report to the Approving Authority(Board
of Health or DEP)within,.3 days of mpleting this inspection. If the system has a design flow of
10,000 gpd or greater, a ins_pact and the system owner shall submit the report to the appropriate
regional office of the D P.T e�ginal 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 ame or different conditions of use.
t5 nsp.doc exev.M6=18 Tille 6 Official Inspection Form Subsurface Sewage Disposal System•Pagei of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
110 Kelley Rd -
Property Address
Jeremiah and Anna Walsh
Owner Owner's Name
information is Hyannis H Ma 02601 3/23/2021
required for every y -
page. Citylrown 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: '
® 1 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 is not a guaranteeand applies no warrantyof the described septic components in this
report including but not limited to piping structual intergrity of components and life exspectancy of
leaching and described.components.This inspection is to describe conditions witnessed at time of
inspection only. Regular tank maintenance and water conservation can prolong life of septic systems
Information on care and do's and don't's can be found at town health dept or mass.gov
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):
1 )
t5insp.doc•rev.7r26 2018. Title 5 Offldel 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
110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owners Name
information is required for every Hyannis Ma 02601 3/23/2021
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 .. Z_Y ❑ N ❑ ND(Explain below):
❑ The system requited,pumpi-ng more thanA times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of'the Board of Health):
t,
❑ broken;pipe(s)are replaced ❑ Y ❑ N. ❑ ND(Explain below):
❑ obstruction is removed ❑ 'Y ❑ N ❑ ND(Explain below):
t
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-mannerwhich will protect public health,:
safety and the environment:
t5insp:doc a rey.'7262018 Idle 5 Official Inspection Forth: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
110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owner's Name
information is required for every Hyannis annis Ma 02601 3/23/2021
page. Cityrrown 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 abordering 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.
i
,
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.7/282018, Title 5 Offidal Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
110 Kelley Rd
zw Property Address
Jeremiah and Anna Walsh
Owner Owner's Name
information is Hyannis Ma 02601 3/23/2021
required for every
page. CitYrrOwn 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 overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than'/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® 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
iof ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
i 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-
010,000 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 bekconsidered 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 mapped Zone_il of.a public water supply well
l5insp.doc•rev.7r am.8 Tide 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 5 or 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owner's Name
information is H annis Ma 02601 3/23/2021
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection.Summary (coot.)
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?
® El available
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
bee#determined.based on:
® ❑ Existing information. For example,_a plan at the Board of Health.
El ElDetermined 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.7262018 Title 6 Ofiaal Inspection Form:Subsurface Sewage Disposal System Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foam-.Not for Voluntary Assessments
110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owner's Name
information is Hyannis Ma, 02601 3/23/2021
required for every
page. Cityrrown 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:
2
Number of current residents:
Does residence have a garbage ghnder? ❑ 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
. t
Seasonaluse? ❑ Yes ❑ No
Water meter readings, if available.(last 2 years usage(gpd)):
Detail:
k
Sump pump? ❑ Yes ® No
Last date of occupancy: current.
_ � Date
45insp.doo•rev.7126/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 7 of 18
I '
Commonwealth of.Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments
110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owner's Name
information is H annis Ma 02601 3/23/2021
required for.every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203) Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):'
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: pate
Other(describe below): .
{
3. Pumping Records:
Source of information: 10-2020
Was.system pumped as}part of the inspection?. . ❑ Yes ® No
1f yes, volume pumped: , :gallons,_;
How was quanti
ty ty pumped:determined?`
Reason for pumping:. I
6insp doc:•rev:7r2612018 Title 5 Official Inspection Form:Subsurface Sewap Disposal System•Page 8 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owners Name
inforrnadon is Hyannis Ma 02601 3/23/2021
required for every Y
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
4. 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
El Other(describe):
Approximate age of all components„date installed (if known)and source of information:
t
2003 existing tank
Were sewage odors detected,when arriving at the.sitlal ❑ Yes 0 No
i
5. Building Sewer(locate on site plan):
2
Depth below grade: ' feet
Material of construction:.
❑cast iron ®40 PVC ❑^other.(explain)`
Distance from rivate.water supply well or suction line: - �et
P. t PP Y feet
Comments(on condition'of joints,venting; evidence of leakage, etc.):.
none.
1
t5insp.dob.�rev:7/26/2018 Title 6 Oflidal 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
110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owner's Name
information is required for everyy Hyannis Mai02601 3/23/2021
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.) .
6. Septic Tank(locate on site plan):
1.5'
Depth below grade: feet
Material of construction:
®concrete ❑metal ❑fiberglass ❑ polyethylene ❑other(explain)
H10 1000 gal tank precast -
If tank is metal, list age: yearn
Is age confirmed by a Cer0cate of Compliance?,(attach.a copy of certificate) ❑ Yes ❑ No.
1000 gallons
Dimensions:
Sludge depth:
26"
Distance from top of sludge to bottom of outlet tee or baffle
less then 1"
Scum thickness
511
Distance from top.of scum to.top of outlet tee or baffle
t
18'r
Distance from bottom of-scum to bottom of outlet tee or baffle
How were dimensions determined? tape and sludge judge
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outletinvert, evidence of leakage, etc.):
tees in place no visable decay or leaks
(Sinsp,doc•rev.726J2018 Title 5 Oflidal Inspection Form Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owners Name
information is Hyannis Ma 02601 3/23/2021
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete El 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.):
I
e
8. 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:p tY: gallons I
I
Design.Flow: gallons per day
.l5insp.d6c rev.7/26/201 a Title 5 Official Inspec06n Form:Subsurface sewage Disposal system•Page 11 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owner's Name
information is Hyannis Ma 02601 3/23/2021
required for every y
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.):
*Attach copy of current pumping contract(regtiired),Is copy attached? ❑ Yes [-I No
9. Distribution Box(if present must be opened)(locate;on site plan):
Depth of liquid level above outlet invert
0
Comments(note if box.ii level and distribution-to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box,.etc)
camera inspected Dbox iappears:sound with no major decay. Box os at working level with no over
staining
f
15insp.doc rev.72812018: 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
110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owner's Name
information is required for every Hyannis Ma 02601 3/23/2021
page. Cityrrown State Zip Code Date of Inspection
D. System Information-.(cont)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order. ❑ Yes ❑ No*
Comments(note condition of pump chamber;condition of pumps and appurtenances, etc.)-
*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:
probed leaching into stone bed°1 foot prob was clean and dry
Type:
❑ leaching pits number:
® leaching chambers number. 4 HI caps
❑ leaching galleries number:
❑ leaching trenches number, length:
P
❑ leaching.fields number, dimensions: -
overflow desspool number:.
l] Innovative/alternative system.
Type/name-of technology:
t5insp.doc-rev.itW2018 Title s Official Inspection Forth:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
110 Kelle Rd
Property Address
Jeremiah and Anna Walsh
Owner Owner's Name
information is Hyannis Ma 02601 3/23/2021
required for every CitylTown State Zip Code• Date of Inspection
page.
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.):
I
12. Cesspools(cesspool must be pumped as part of.inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool;
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note.condition,of soil, signs.of hydraulic failure, level of.ponding, condition of vegetation,.
etc.):
i
{
t
Wnsp.doc•rev.726/2018. Title 5 OfTiaal Inspection Forth:Subsurface Sewage Disposal System•Page 14 of18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owner's Name
information is Hyannis Ma . 02601 3/23/2021
required for every
Page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition:of soil, signs of.hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
l . .
i .
t5insp.doc-rev.72SW1 W F Title 5 Oftidal Inspection Fomr.Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments
110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owner's Name
information is required for every Hyannis Ma. 02601 3/23/2021
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
9 D6-
4
A3 3
t5msp.doc!rev.726=18. ' Title 5 Official Inspecton'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
110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owner's Name
information is Me. 02ti01 3/23/2021
required for every Hyannis
page. City/Town State Zip Code Date of Inspection
D. System Information (cone)
15. Site Exam:
® Check.Slope
® Surface water
® Check cellar
® Shallow wells
greater then 11'
Estimated depth to high ground water. feet
Please indicate all methods used.to.determine thehigh ground water elevation:
® Obtained from system design plans on record
If checked, date of desi n Ian:reviewed: 2003
9 P Date
❑ Observed site(abutting property/observation,hole Within 156 feet of SAS)
❑ Checked with local Board of Health-,.explain:,,
III
❑ Checked with local excavators, installers--(attach documentation)
❑ Accessed USGS database-explain:
You must describe how;you established the high_ground,waterelevation:
no water on perc. system was installed per Title 5,regs and..engineered plans, inspected and COC
was issued from bamstable health dept.
i
T ,
t
t
Before filing this Inspection Report;,please see Report Completeness Checklist on next page.
t5lnsp.doc-rev.M2612018 Me Official Inspection Form Subsurface Sewage Disposal System Page V of 18
Commonwealth of Massachusetts;
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forme-Not_forVoluniary Assessments
110 Kelley Rd
Property Address
Jeremiah and Anna Walsh
Owner Owner's Name
information is required for every Hyannis annis Ma 02601 .3/2372021
page. Cityrrown State Zip Code Date of Inspection
E. Report,Completeness Checklist
Complete all applicable sections of this form inclusiVe of:
® A. Inspector Information: Complete all fields"in.this.section.
0 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/HoldingT an,k=Pumping contract attached
For 14: Sketch of Sewage-Disposal,$ystem>drawn on;pg. 16 or attached
For 15: Explanation of estimated depth to:high groaindwater included
F
• f
f
t '
t5lydp doc.�7ev:'7r282018, Title 5 Official Inspection Forms subsuAece Sewage Disposal System-.Page 18 of 18
c
Fee
No. U -
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpprication for �Digool *p5tem ttCongtruction Permit
Application for a Permit to Construct( . )Repair( a Upgrade( )Abandon( ) Complete System' ❑Individual Components
Location Address or Lot No. I%D-" Ala-, Owner's Name,Address and Tel.No. —7 7'
Assessor's Map/Parcel S '/p
Ins is Name,Address�No. So8-�� f3—Cbz De 'gner's N"e,Address aro Tel.No.
Type of Building:
Dwelling No.of Bedrooms 19 Lot Size sq.ft. Garbage Grinder( )
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 /S-eoP Type of S.A.S.
Description of Soil
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 not to place the system in operation until a Certifi-
cate of Compliance has been issued t is Board of 11e
Signed Date -7-
Application Approved by Date 3
Application Disapproved for the following reasons
Permit No. �2UO.3-095 Date Issued 3_�-0 3
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k�t No. ��UUZ� ... ��.,.�. Fee
f Entered in computer:
THE COMMONWEALTH OF MASSACHUSETTS Yes
i p
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Rpplication for Migpogar *pgtem Congtruction Vermit
Application for a Permit to Construct( . )Repair Upgrade( )Abandon( ) Xcomplete System ❑Individual Components
Location Address or Lot No. � Owner's Name,Address and Tel.No. -7 7 S--9/ /Z
Assessor's Map/Parcel
Installer's Address,and Tel.No. 508-7 Des'gner'ANeAddress and Tel.No. j Og 3�v� 'XI '2'
I��. �
a
Type of Building:
Dwelling No.of Bedrooms 13 Lot Size sq.ft. Garbage Grinder( )
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 p
Size of Septic Tank /64a p-e Type of S.A.S. Zleto �u,•
Description of Soil
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 not to place the system in operation until a Certifi-
cate of Compliance has been issued by[his Board'ofyHealth.
Signed Y ' Date 3- 4--iP3
Application Approved by Date
Application Disapproved for the following reasons
Permit No. �2 Uo 3"D 9S Date Issued 3-A-0 3
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
THIS IS TO ER , that the 09,site . wage Disposal System Constructed ( )Repaired (,,-I Upgraded( )
Abandoned( )by �..a�� km
at //D mil , U�ftGT�6Cj1; /1ye-- . "3; has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. j.;00- =USS` dated
Installer Designer K
" The issuance of irshall not be construed as a guarantee that the syste b 'o �a s' r
Date I 6 Inspectors x
rff e 6.
Y
— DUB- -- ---- ----- Fee `
No.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS
1wig;p0al *pgtem Congtructton 3permit
Permission is hereby granted to Construct( )Repair(A,,rupgrade( )Abandon( )
System located at //G
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.
9
Provided: Construction must be completed within three years of the date of thi errm/�.
Date:_ 6 rl Approved by ✓ �' ��
!. TOWN OF BARNSTABLE A
LOCATION SEWAGE #VILLAGE �
— ASSESSOR'S MAP & LOT a
INSTALLERS NAME&PHONE NO. �
SEPTIC TANK CAPACITY ? G c\\
LEACH N9 FACILITY: (type):. LI�>>�-�•���. (�
(size)
NO. OF BEDROOMS •� �o a
1�' f
II-
BUDER.OR OWNER.._ Y`�\1�n
PERMiTDATE: (a Jo3 COMPLIANCE DATES/IT 0
Separation Distance Between the-
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility NA Feet
Private Water Supply Well and Leaching Facility (If any.wells exist /1/ J�
on site or within 200 feet of leaching facility) (B / Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 306 feet of leaching facility) N)'�__Feet
Furnished by
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TOWN OF BARNSTABLE
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LOCATION'S z- SEWAGE #
�' �S. ASSESSOR'S MAP & LOT 1
INSTk-,LER'S NAME&PHONE NO. Q., : �XV-\G\�N
SEPTIC TANK CAPACITY*- C\
LEACHING FACILTTY:,_(type) LAI `'��� (� (size) Q .k(_TX k
NO.OF BEDROOMS" POel>
BLftLDER OR OWNER
PERMTTDATE: _7 �6� COMPLIANCE DATES 07
Separation Distance Between the;
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility NA Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) fE Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) AA Feet
Furnished by
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LOCATION SEWAGE PERMIT NO.
4,
V't L A G E u0:
PARCEL NO...
INSTALLER'S NAME i ADDRESS
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0 U I L D E R OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE. ISSUED
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ACCESS COVERS MUST BE WITHIN 9' MINIMUM. INVERT ELEVATIONS : DESIGN CRITERIA : GENERAL NOTES :
6' OF FINISH GRADE 3' MAXIMUM COVER
INVERT AT BUILDING: 100. 1 DESIGN FLOW:
103. 79 FIRST 2 ' TO
BE LEVEL MIN 2' OF PEAS TONE INVERT IN SEPTIC TANK: 97, 75 3 BEDROOMS AT 110 G.P.D. PER I. THIS PLAN /S FOR THE DESIGN AND CONSTRUCTION
INVERT OUT SEPTIC TANK: 97,5 BEDROOM EQUALS 330 G.P.D. OF THE SEWAGE DISPOSAL SYSTEM ONLY.
4' DIAM PI INVERT IN DIST. BOX: 97.25
3/4- - 1 1/2' D I A. NO GARBAGE GRINDER 2. VERTICAL DATUM IS ASSUMED. FOR BENCH MARKS
I o 7 �8 I0- DOUBLE WASHED STONE INVERT OUT DIST, BOX: 97, 08
1
rAs 96. 17 17 _ " INVERT IN LEACH CHAMBER: 97.0 SET. SEE SITE PLAN.
97• BAFFLE S 0 SEPTIC TANK REQUIRED:
3 OUTLET 4 HIGH CAPACITY INFILTRATOR ` / �� go. 00 BOTTOM OF LEACH CHAMBER: 96. 17 330 G.P.D. X 200X 660 GAL . 3. ALL CONSTRUCTION METHODS AND MATERIALS AND
D-BOX
CHAMBERS W/3. 5 •t STONE AROUND " 4�[o ADJUSTED GROUND WATER: N/A SEPT I C TANK PROVIDED: 1500 GAL . MIN. MAINTENANCE OF THE SEPTIC SYSTEM SHALL
1500 GAL 10 .w x 38 '1 x 10'd ?S OBSERVED GROUND WATER: N/A CONFORM TO MASS. D.E.P. TITLE 5 AND LOCAL
SEPTIC TANK 6' CRUSHED STONE OR
BOTTOM OF TEST HOLE *l : 90. 0 SOIL ABSORPTION SYSTEM REQUIRED: BOARD OF HEALTH REGULATIONS.
COMPACTED BASE
DESIGN PERC RATE l 5 MIN/INCH
PROF- I L E : NOT TO SCALE SOIL TEXTURAL CLASS - 1 4. ALL SEPTIC SYSTEM COMPONENTS LOCATED UNDER
EFFLUENT LOADING RATE - 0. 74 GPD/SF AREAS SUBJECT TO VEHICULAR TRAFFIC OR GREATER
330 GPD / 0. 74 GPD/SF - 446 S.F. REQUIRED THAN 3' IN DEPTH SHALL BE CAPABLE OF WITH-
STANDING H-20 WHEEL LOADS.
PROVIDED: 4 HIGH CAPACITY INFILTRATOR
N CHAMBERS W/3. 5 '1 STONE AROUND, A-460 S.F. 5. ALL SEWER PIPE SHALL BE SCHEDULE 40 OR
460 S.F. x 0. 74 - 340 GPD APPROVED EQUAL.
6. SEPTIC TANK AND D-BOX SHALL BE REINFORCED
SO I L TES T P I T DA TA S PRECAST CONCRETE AND WATERTIGHT. D-BOX SHALL
I ND I CA TES I ND I CA TES BE WA TER TES TED TO CHECK FOR L EVEL WHEN THERE
PERCOLATION OBSERVED IS MORE THAN ONE OUTLET.
TEST GROUNDWATER
7. BEFORE CONSTRUCTION CALL 'D 1 G-SAFE..
TP 1-688-DIG-SAFE AND THE LOCAL WATER DEPT.
L 0 T 70 d SOUTH 0' HORIZON TEXTURE COLOR 100. 0 FOR LOCATION OF UNDERGROUND UTILITIES.
112 OF LOT 71 '9 "is-E ' F l L L
�_ 8. EXISTING CESSPOOL TO BE PUMPED DRY AND
SFO o � � BACKFILLED.
14 314 + S. F. F��`' 99.5
°O LOAMY I OYR
• _ �, SAND 2/2
ry p BM CORNER BULKHEAD °FNCE — (0' 99.2
EL-roe 69 p LOAMY IOYR
y D
SAND 3/6
r ( W 32 97. 3
ABOVE GRouN� Op C / MEDI UM 10YR
r i POOL SAND 5/6
h o° DIE OF o
o BR I Cx PAO Ir �, 48
�1500 GALLON I
SEPTIC TANK SYs
♦ rl � � 120. � NO WATER _ 90. 0
W GARAGE � Q
DECK o , T '" o� 'P DATE: DECEMBER 13, 2002
p
TEST BY. STEPHEN HAAS
Is. D Box �"--� WITNESSED BY: DAVID STANTON
PERC RATE: C 2 MIN/INCH
!� SPOCAAD _
i 4 HIGH CAPACITY �ENC
h !
/ INFILTRATOR CHAMBERS
/V /4O °° ' I N/3.5'1 STONE AROUND
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/ / O K E L L Y W,4 Y . M 4 P 2 9 2 . P,4 R C E L .5 8
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,� MA S S C,4 P E C O N S T R U C T / O IV
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SC.4L E : / — 20 . —/ANLIAR Y 13 , 2003
EAGLE SURVEYING , INC
923 RcDu t e 6A
r t Ya rmo u t hi p o r t MA 02675
( 508 ) 362-8 1 32
5 0 8 �
1
L O C U S MA P 0 10 20 40 JOB NO: 02 267 F!EL D:CFW/EEK FCALC: SAH/CFW CHECK: CFW DRN: SAH