HomeMy WebLinkAbout0019 LAFAYETTE AVENUE - Health 19 LAFAYETTE AVENUE, HYANNIS
A = 287 044
J
,i
TOWN OF BARNSTABLE
LOCATION'/_ �� rrri 2�1��. SEWAGE# c� CQ� �`
VILLAGE/, �r�r;�,> �r�`' ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NOr a3
SEPTIC TANK CAPACITY 1 w e yJ — -0
y.
LEACHING FACILITY:(type) f" (size) 0 )&
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: ��f 2�J��� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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) t /rf��' Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leac ' g facility) Feet
Furnished by � ;
� W �
T
3
O 000
�A
No. ® O Fee € ��
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2pplication for -Misposal *pstrm Construttiun 3dermit
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System U4r ividual Components
Location Address or Lot No. If/-4*91_65 77 Owner's Name A dr ssand Tel.No.
Assessor's Map/Parcel �'/O y �4/ dDesigner's
� �� C ' Z'
I �aig�,Adfdres�dGTel. o.,SO �% Z Name,Address,and Tel.No.
C d
Type of Building: Q 16 y�
Dwelling No.of Bedrooms Lot Size r�. ft. Garbage Grinder( )
Other Type of Building /F No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
zZ
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
'Compliance has been issued by this Board of He
Si �.�.� Date
Application Approved by l Date eS
Application Disapproved by Date
for the following reasons
Permit No. I o Date Issued S e
No. V - Fee- bC�
THE COMMONWEALTH OF MASSACHUSETTS Entered uicomputer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYication for Disposal *pstem Construction Permit
Application for a Permit to Construct( ) Repair Upgrade( ) Abandon( ) ❑Complete System 0;adi`v_idual Components
Location Address or Lot No. �9 �1�i9��77�C��/�v Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer's Name,Address and Tel. o.S' -7ysyS Designer's Name,Address,and Tel.No.
L'✓f��- L'rld
Type of Building:
Dwelling No.of Bedrooms Lot Size /�, ) (� .ft. Garbage Grinder( )
Other Type of Building it No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan .Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
/S lJ r c t
d -
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Hea
Si a /� Date ® a'
Application Approved by Date v
Application Disapproved by Date
for the following reasons
Permit No. .r c V r U Date Issued - 2 p z
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
� L }gin fc Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(�%� Upgraded( )
Abandoned( )by �Z � Q/�,/,�i ,r%� �� .�Q 4W2, — !
at /OF has been constructed in accordance
with the provisions o Title 5 and the for Disposal System Construction Permit No.2�_J 'L dated .2 0
I
Installer Designer
#bedrooms Approved design flow gpd
The issuance of this permit s all not be construed as a guarantee that the system will fu ' n as signed.
Date r, Inspector 14
---- - --/-�-- p - - ------- --------- --------- - - -
No. 0 / I!1 U Fee 0�THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
3Disposal *PstT Construction Permit
Permission is hereby granted to Construct( ) Repair I Jngrade( ) Abandon( )
System located at e 9If 17
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construct' n mus be completed within three years of the date of this permit 42
Date ,�c i Approved by
p�Q�11owti Town of Barnstable Barnstable
M�ftedc
Inspectional Services aC I.F
BARrABLE;"�" Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas A.McKean,CHO
FAX: 508-790-6304
4
CERTIFIED MAIL#7015 1730 0001 4987 7718
April 17, 2019
GRAVES, MEREDITH M TR
202 ROCKLAND ROAD
MONTCHANIN, DE 19710
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 .
The septic system located at 19 Lafayette Avenue, Hyannis was inspected on
02/20/2019 by Douglas A. Brown, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
• The H10 septic tank is located under the driveway. The septic tank must be
upgraded to H2O or the driveway needs to be relocated.
You are order"ed to'repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
ean, R.S., CHO
Agent of the Board,of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Conditionally Passes Letters\19 Lafayette Avenue Hyannis.doc
Town of Barnstable
r r
a r
+ &"NSfABLE,
9�p A639. ,� Regulatory Services Department
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 5/11/16
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1) YEAR DEADLINE CRITERIA '
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool
y"conditionally passed systems" (broken cover, relocation of a pipe, relocation
f a driveway due to H-10 components, etc)
❑ Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h)
OTHER
Repair deadline:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
1
o2 S-7- o(f q
Commonwealth of Massachusetts
(o Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Lafayyette Ave
Property Address
Meredith Graves r°
Owner Owner's Name =+�
information is
required for Hyannisport Ma 2-20-19
every page. Cityrrown State Zip Code Date of Inspection
� 1
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.
p When Important: A. Inspector Informationa
When filling out
forms on the
computer,use Douglas A Brown
only the tab key Name of Inspector
to move your D.A. Brown Inc
cursor-do not Company Name
use the return
key. P.o. Box 145
Company Address
Centerville Ma 02632
City/Town State Zip Code
508-420-4534 Sf4297
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
2-20-19
Inspecto 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
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
every 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:
❑ 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:
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 exMtration 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):
The septic tank is under the driveway and listed as h-10 on inspection report dated 7-13-98 by
Robinson Septic. Even though it passed in 1998 since then the rule on this has changed requiring it
to be replaced with an h-20 tank or removing the driveway in the area of the septic tank making
unable to be parked or driven on.
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.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
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.7Y26/2018 Title 5 Official Inspection Farm: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
19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
every 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 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:
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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
I
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
11. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
every page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
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 groundwater elevation.
0 ® 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
i
cam, Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
every page. Cityrrown 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
�v = Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
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:
Number of current residents:
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 El Yes El No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Water readings were not available at the time I typed this report. This system is not designed for use
with a garbage disposal.
Sump pump? ❑ Yes ❑ No
Last date of occupancy: seasonal
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
every page. Cityr town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
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):
3. Pumping Records:
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cost.)
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.
® Other(describe):
Tank and pit no d-box shown
Approximate age of all components, date installed (if known) and source of information:
according to previous inspection report the pit was installed in 1976
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
le Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Previous inspection report states tank is not H-20 and is under driveway. There is 1 access cover.
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 per as-built
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. 19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
every 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:
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:
Material of construction:
❑ 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4�
19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
every page. City/Town State Zip Code Date of Inspection
D. System Information (coot.)
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):
Depth of liquid level above outlet invert NA
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
every 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:
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
I
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
f;
1 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
every page. Cityrrown 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.):
Pit was opened and was dry at time of inspection. Pit is from 1976. This report can not predict the
future performance under the same or increased usage
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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
every page. Citylrown 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 16 of 18
I
c Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: greater than 12
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:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
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
Commonwealth of Massachusetts
(o Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
19 Lafayyette Ave
Property Address
Meredith Graves
Owner Owner's Name
information is
required for Hyannisport Ma 2-20-19
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.
® 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
" e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 Lafayette Ave. Hyannisport Ma.
Owner: R.Clark III
Date of Inspection: 7-13-98
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)
N v
(revised 04/25/97)
Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 Lafayette Ave. Hyannisport Ma.
Owner: R.Clark III
Date of Inspection: 743-98
Depth to groundwater 15 plus Feet
Please indicate all the methods used to determine High Groundwater Elevation:
x Obtained from Design Plans on record
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
Obtained from as-built; Board of Health.
i
f
(revised 04/25/97)
Page 10 of 10
TOWN J'BARNSTI L3LE
Jl ATiI.`N SEWAGE #
`ALLAGE UViMili5 DOCK' ASSESSOR'S MAP & LOT
1ASTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY I Soo OT I t F S IS
LEACHING FACILITY: (type) I� ��� DIOLk (size)
NO. OF BEDROOMS 3
BUILDER OR OWNER ��AfK►
PERMU DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility1 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 coo •
_ _ k
, 3
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR G ,A
PART A
CERTIFICATION a .o
Map Number 287 ��z '. VIV
Parcel Number Lot—C
PROPERTY ADDRESS: 19 Lafayette Ave. Hyannisport Ma. ADDRESS OF OWNER:
DATE OF INSPECTION: 7-13-98 5640 Bent Branch
NAME OF INSPECTOR: Wm. E.Robinson Jr. Bethesda Md.20816
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: W. E. Robinson Septic Inspections
MAILING ADDRESS: 43 Tomahawk Drive Centerville, MA 02632
TELEPHONE NUMBER: (508)775-7986
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:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FALLS
INSPECTORS SIGNATURE: §12 DATE: 7-13-98
The system Inspector shall submit a copy of this inspection report to the/Pproving 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:
A] SYSTEM PASSES:
X . 'I have not found any information which indicates that the system violates any of the failure criteria as
defined in 310 CMR 15.303. Any failure,criteria not evaluated are indicated below.
COMMENTS: 1500 GST and,one LP-1000 in driveway in good working condition at time of inspection.
System is Title 5 but tank is not;H-20: .
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 b the Board of Health,
will.pass.
Indicate yes, no, or not determined (Y, N, or NO). 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 is 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.
Page 1 of 10
(revised 04/25/97)
DEP on the World Wide Web:http://www.magnet.state.ma.un/d
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (CONTINUED)
Property Address: 19 Lafayette Ave. Hyannisport Ma.
Owner: R.Clark III
Date of Inspection: 7-13-98
B]SYSTEM CONDITIONALLY PASSES(continued)
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 leveled 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:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH 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.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER
SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A
MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
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
1 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 and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine
distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 19 Lafayette Ave. Hyannisport Ma.
Owner: R. Clark III
Date of Inspection: 7-13-98
D]SYSTEM FAILS:
You must indicate either"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 over-
Loaded 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'/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 Soil Absorption System, cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 feet of 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)LARGE SYSTEM FAILS:
You 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
mapped Zone II of a public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of
the Department for further information.
(revised 04/25/97)
Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 19 Lafayette Ave. Hyannisport Ma.
Owner: R. Clark III
Date of Inspection: 7-13-98
Check if the following have been done: You must indicate either"Yes"or"No" as to each of the following:
Yes No
yes Pumping information was provided by the owner, occupant, or Board of Health.
Yes None of the system components have been pumped for at least two weeks and the system
has not 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.
Yes As built plans have been obtained and examined. Note if they are not available with N/A.
Yes The facility or dwelling was inspected for signs of sewage back-up.
Yes The system does not receive non-sanitary or industrial waste flow.
Yes The site was inspected for signs of breakout.
Yes All system components, including the Soil Absorption System, have been located on the site. ,
Yes 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:
Yes The facility owner(and occupants, if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
Yes Existing information. Ex. Plan at B.O.H.
Yes 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)]
(revised 04/25/97)
Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 19 Lafayette Ave. Hyannisport Ma.
Owner: R. Clark III
Date of Inspection: 7-13-98
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 110 g.p.d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current.residents: 2
Garbage grinder(yes or no): No
Laundry connected to system es or no): Yes
Seasonal use(yes or no) Yes
Water meter readings, if available(last two(2)year usage(gpd): 97-98 30000 gals.
Sump Pump(yes or no): No
COMMERCIAL/INDUSTRIAL: none
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no):
Industrial Waste Holding Tank present: (yes or no)
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Tank cleaned 7-13-98 (maintance) TOB
System pumped as part of inspection:(yes or no) Yes
If yes, volume pumped: 1500 Gallons
Reason for pumping Tank needed cleaning.
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system Note; no D-box
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:
Overflow installed in 1976 AS built card B.O.H.
Sewage odors detected when arriving at the site: (yes or no) no
(revised 04/25/97)
Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 19,Lafayette Ave Hyannisport Ma.
Owner: R. Clark III
Date of Inspection: 7-13-98
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 3099
Material of construction x Cast iron 40 PVC _ other(explain)
Distance from private water supply well or suction line 15 ft-town water
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:.;
(Locate on site plan)
Depth below grade: At grade
Material of construction X Concret Metal Fiberglass Polyethylene, other(explain)
e
If tank is metal, list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: 11'x5'x5' 1500 GST
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 38"
Scum thickness: 5"
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: 5"
How dimensions were determined Measured
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet
invert, structural integrity, evidence of leakage, etc.)
Tank cleaned as part of inspection.
NOTE; outlet cover on tank is under pavement and should be raised to grade.
GREASE TRAP: none
(locate on site plan)
Depth below grade:
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:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet
invert, structural integrity, evidence of leakage, etc.)
(revised 04/25/97)
Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 Lafayette Ave.Hyannisport Ma.
Owner: R.Clark III
Date of Inspection: 7-13-98
TIGHT OR HOLDING TANK: None (Tank must be pumped prior to, or at time, of inspection)
(Locate on site plan)
Depth below grade:
Material of construction _ Concrete _ Metal _ Fiberglass _ Polyethylene _ other(explain)
Dimensions:
Capacity:
Design flow: T Gallons/day
Alarm level: Alarm in working order _ Yes; _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition Hof alarm and float switches,etc.)
DISTRIBUTION BOX: None;
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc,)
PUMP CHAMBER: none
(locate on site plan)
Pumps in working order: (Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97)
Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 19 Lafayette Ave.Hyannisport Ma.
Owner: R. Clark III
Date of Inspection: 7-13-98
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: 1
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
leaching fields, number,dimensions:
overflow cesspool, number, 1-
alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of Ihydraulic failure, level of ponding, condition of vegetation, etc.)
One LP-1000,dry at time of inspection. LP 1000 is in like new condition.
CESSPOOLS: None;
(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)
Comments::
(note condition of soil, signs of hydraulic failure, , level of ponding, condition of vegetation, etc.)
PRIVY: none
(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.)
(revised 04/25/97)
Page 8 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 Lafayette Ave. Hyannisport Ma.
Owner: R.Clark III
Date of Inspection: 7-13-98
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)
IV U
L6Fq TT6
(revised 04/25/97)
Page .9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 19 Lafayette Ave. Hyannisport Ma.
Owner: R.Clark III
Date of Inspection: 7-13 98
Depth to groundwater 15 plus Feet
Please indicate all the methods used to determine High Groundwater Elevation:
x Obtained from Design Plans on record
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
Obtained from as-built; Board of Health.
} (revised 04/25/97)
Page 10 of 10