HomeMy WebLinkAbout0204 MITCHELL'S WAY - Health 204 Mitchell Way
Hyannis `
A= 290-144
f e ,�
Commonwealth of Massachusetts o —
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Mitchells Way ;
Property Address r ,
North Atlantic Realty
Owner Owner's Name/
information is required for every Hyannis V MA 02601 05/12/2021 c
page. cityrrown 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.
'm when
fillingng out A. Inspector Information 5! 15ct Is
out forms
on the computer,
use only the tab A.Riker
key to move your Name of Inspector
cursor-do not Cape Dig Inc.
use the return Company Name
key.
PO Box 726
,� Company Address
South Yarmouth MA 02664
City/Town State Zip Code
508-776-6460 SI-4590
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 16.000); 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
05/12/2021
Ins or'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;600-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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Mitchells Way
'Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
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:
Septic tank and leach pit was observed to be in working conditon with no failures observed .
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", "non or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain. -
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):,
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Tilde 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
page. City(rown 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):
El 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
ElThe 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.
El 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 ifthe 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.7f2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
jr
204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
Required pumping_more than 4 times in the last year NOT due to clogged or
❑ ® obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section C.4.
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
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
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)
E ❑ 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.W26/2618 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
c � Commonwealth of Massachusetts.
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes [ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
2020=66 GPD
2019=70 GPD
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
'n F Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Mitchells Way
Property Address `
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
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: Date
Other(describe below):
3. Pumping Records:
Source of information: none avalible
. .
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: regular pumping recommened due to age of system
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
to Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ 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:
no file avalible at town to confirm age of system
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 3
feet
Material of construction: C
❑ 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.):
dry with no signs of failure or back ups observed
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 1.7
feet
Material of construction:
E concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
Risers placed on inlet and outlet
Concrete baffles on inlet and outlet in place with no defects
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
5x5x8.5'
Sludge depth:
10"
Distance from top of sludge to bottom of outlet tee or baffle
24"
Scum thickness 4"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined?. Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
No signs of failure or high water stains observed. There were roots observed at inlet pipe and they
were removed and pipe cleared.
t5insp.doc•rev.7/26/2018 Title 5 Official 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
204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
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 ❑ 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
204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*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 no D-box
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.):
Na.
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
j' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
L 204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is H annis MA 02601 05/12/2021
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.):
* 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: single 6x6 leachpit
❑ leaching chambers number:
❑ leaching galleries number:
❑ Teaching 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
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
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.):
**" Leach Plt had 13" of liquid level in base with no high watyer stains obsevred
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1� 204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
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.):
x
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 Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
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
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t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
page. City/Town 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: no water at 10'
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:
Abutting property with elevation changes and hand augur
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
9 p Y rY
204 Mitchells Way
Property Address
North Atlantic Realty
Owner Owner's Name
information is required for every Hyannis MA 02601 05/12/2021
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector information:�Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
i
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
Seasonal Pools that have not applied in Year 2021
Breakwater 432 Sea Street, — Lifeguard Dereg, QS Outdoor Pool
Condos H
Cape 800 Bearses — LG,QS Outdoor Pool
Crossroad Way,H
Cape Glen 329 W.Main — QS Outdoor Pool
Street,H
Capt.Gosnold 230 Gosnold Lifeguard Dereg. Outdoor Pool
Village Street,Hy —
*Building
New Pool
Craig.Beach 369 S.Main Lifeguard Dereg. Indoor Pool
Inn Street,Hy Motel
Hyannis Plaza r Pool
Hotel Hy Motel
Lamb&Lion 2504 Main — QS/Lifeguard Dereg. Outdoor Pool,Outdoor
Inn Street,Barn Hot Tub
Weeke's 210 Percival — Lifeguard Dereg. Outdoor
Commonwealth of Massachusetts
Title- 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Y 204 Mitchells Way
Property Address
Homeward Residential
Owner Owner's Name
information is Hyannis Ma. 02601 7/6112 required for every H 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. General Information
` I
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Brian S. Lane
use the return Name of Inspector
key.
Lane Septic Inspection Service
—� Company Name
1 State St.
Company Address
Walpole Ma. 02081
City/Town State Zip Code
508-212-2916 laneseptic@verizon.net 2280
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
r 7/7/12
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 is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
f ""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.
I
t5ins•11/10 Ti'V,.t.norm:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form_-Not for Voluntary Assessments
w� 204 Mitchells Way
Property Address
Homeward Residential
Owner Owner's Name
information is
required for every Hyannis Ma. 02601 7/6112
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N;ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System form-Not for Voluntary Assessments
�M 204 Mitchells Way
Property Address
Homeward Residential
Owner Owners Name
information is required for every Hyannis Ma. 02601 7/6/12
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•1 MO Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
204 Mitchells Way
Property Address
Homeward Residential
Owner Owner's Name
information is y
required for every Hyannis Ma. 02601 7/6/12
page. CityrFown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of,Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
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.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
't 204 Mitchells Way
Property Address
Homeward Residential
Owner Owner's Name
information is required for every Hyannis Ma. 02601 7/6/12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ Z 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
tributaryto a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
204 Mitchells Way
Property Address
Homeward Residential
Owner Owner's Name
information is y required for every Hyannis Ma. 02601 7/6/12
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ Z 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)]
D. System Information
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
t5ins-11/10 Title 5 Official Inspection Fond:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth&Massachusetts
Title 5 Official, Inspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 204 Mitchells Way
Property Address
Homeward Residential
Owner Owner's Name
information is required for every Hyannis Ma. 02601 7/6/12
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage water shut off
9 ( y 9 (gPd}):
Detail:
water was shut off on 9/21/11 prior to that 83 gpd avg use
Sump pump? ❑ Yes ® No
Last date of occupancy: prior to 9/21/11
Date
CommerciaUlndustrial 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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°r 204 Mitchells Way
Property Address
Homeward Residential
Owner Owner's Name
information is H annis Ma. 02601 7/6/12
required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: unknown
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval
® Other(describe):
septic tank and leach pit no d-box
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
204 Mitchells Way
Property Address
Homeward Residential
Owner Owner's Name
information is required for every Hyannis Ma. . 02601 7/6/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
38 years old certificate of compliance dated 12/3/1974
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 3'feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: town water see sketch
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
joints tight no visible leaks
Septic Tank(locate on site plan):
Depth below grade: 1.7
feet
Material of construction: 1
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:_ years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8x5x5 1000gal
Sludge depth: 511
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
204 Mitchells Way
Property Address
Homeward Residential
Owner Owners Name
information is required for every Hyannis Ma. 02601 7/6/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
1
Distance from top of scum to top of outlet tee or baffle
10"
Distance from bottom of scum to bottom of outlet tee or baffle 13 1/2"
How were dimensions determined? tapemeasure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
tank isconcrete in good condition, no evidence of leakage, concrete inlet and outlet"T"s present, liquid
level is at outlet invert, does no require pumping at this time
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
t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
204 Mitchells Way
Property Address
Homeward Residential
Owner Owner's Name
information is required for every Hyannis Ma. 02601 7/6/12
page. Cityr town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in workingorder: 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
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
204 Mitchells Way
Property Address
Homeward Residential
Owner Owner's Name
information is required for every Hyannis Ma. 02601 7/6/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert none present with this system
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located,explain why:
t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
204 Mitchells Way
Property Address
Homeward Residential
Owner Owners Name
information is
required for every Hyannis Ma. 02601 7/6/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp'soil, condition of
Vegetation, etc.):
no evidence of hydraulic failure, soil is dry sand and gravel, vegetation is lawn in normal condition,
leach pit is dry no liquid
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
t5ins-11/10 Title 5 Official Inspection forth:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 204 Mitchells Way
Property Address
Homeward Residential
Owner Owner's Name
information is required for every Hyannis Ma. 02601 7/6/12
page. Citylrown State Zip Code Date of Inspection
D. System Information(cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-11/10 Title 5 Offidel Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 204'Mitchells Way
Property Address
Homeward Residential
Owner Owner's Name
information is required for every Hyannis Ma. 02601 7/6/12
_-
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
❑ drawing attached separately
J J Z i a 5'
L-6)4Cf/�a' T 34-. 5`
LeArrR t T-
2
szvr)C-t*V4'
p� G7 V All kle
In
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4'B N_z
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t5ins•11110 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official -Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
204 Mitchells Way
Property Address
Homeward Residential
Owner Owner's Name
information is required for every Hyannis Ma. 02601 7/6/12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 10'+
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
z 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:
leach pit was found to be dry at 8.5' rod driven 1.5' more into bottom and was still dry
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
204 Mitchells Way
Property Address
Homeward Residential
Owner Owners Name
information is required for every Hyannis Ma.; 02601 7/6/12
page. Cityrrown State . Zip Code Date of Inspection .
E.- Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
F
t5ins•11/10., Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Town of Barnstable
. � t �. Regulatory Services
Thomas F. Geiler,Director
'NAM Public Health Division
h�
Thomas McKean, Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
MAIL TO:TOWN OF BARNSTABLE
PUBLIC HEALTH DIVISION
200 MAIN STREET
HYANNIS,MA 02601
FAX:508-790-6304
SEPTIC SYSTEM INSPECTOR REGISTRATION
Fee: $25.00 per report
Date 2
Name of DEP Certified Inspector 4//e"k4
Business Address < j-E !n CEO 8l
Business Telephone No. .So 2 12, 2-9
FAX Number
Home Address ed¢
Home Telephone Number Xvgl—
The undersigned agrees to comply with PART VIII, SECTION 14.00 of the Board of
Health Regulations. `The septic system inspector shall complete every applicable section of the"Title 5
Official Inspection Form-Not For Voluntary Assessments, Subsurface Sewage Disposal System Form,"
supplied by the Massachusetts Department of Environmental Protection. In addition,at the bottom of the
last page of this official inspection form,the septic system inspector shall provide a sketch diagram showing
the vertical separation distance between the bottom of the soil absorption system and the groundwater table
along with any high groundwater elevation adjustments determined. The Septic System Inspector shall
submit a copy of the completed septic system inspection report along with the required processing fee to the
Public Health Division Office within 30 days of the inspection date.'
Signature of Applicant
INSTRUCTIONS
Q/health/Wpfiles/sept-insp-registration.doc
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VILLAGE
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BUILDER 5 Q &MF- ADDR'E SS
DL�,TE PERNAVT
D ATE COMPLI &&ICE ISSUED : � 3
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THE COMMONWEALTH OF MASSACHUSETTS
} BOAR® OF HEALTH
ToOF...... ...:..........
Appliratinn for Disposal Worko Tonstrnrtion Pprntit
Application is hereby made /r a Permit to Construct ( ) or Repair ) an Individual Sewage Disposal
System at: m , o
...........JlJ .................................•.........---• .....--
Loc i /Addr�esJs ,�� or Lot No:
O eL / Address--......-•----•-•-••......•--••---•-•-
¢---.•--------- -------•--•--------•-------•----------...__-
nstallet Address
d Type of Building Size Lot............................Sq. feet
V Dwelling 7-No. of Bedrooms______________________________ __ ____Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ............................ No. of persons_--_-_______________-_____ Showers ( ) — Cafeteria ( )
Q' Other fixtures ---------------------------------------------------•--------.
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter---------------- Depth__--------------
x Disposal Trench—No________............ Width....................Total Length____-__-___--._.--__ Total leaching area____-___-__-__--_-_sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet-----_______-____- Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date--------------------------------------..
a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_._____________-________
rZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
04 -------------------------------------------•--------------------------------------------------------.........................................................
0 Description of Soil........................................................................................................................................................................
U -------------------------•••-----•••--•------••-----•-•-•-•••---•---••-------------------•--.....-•---------•------•------•-•------•-•--•--------------------------....----------------...-----•------
- ------------------------------------------------------------------------------------------------------ ....... -------- y�
V Na, ore:of Repairs o lterati ss-AI Ans er wh applicable.__ ___._ ..._._._,�1011��.� --- (�
greement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee y sued b?v the board of health.
S ed1-7 _
.......... Date
` ------
Application Approved By •. . ' 1." Date
Application Disapproved for the following reasons: ------•----------------------------•-•-----••------------------••----•-------•---•••------.
------------•--••---------•-------•---------•----------------------••-----•-----------------•--......_..........---•-------------•---- : : .
J '7 Date
r.
PermitNo......................................................... Issued--- ---------------............... .yC
Date
V
----------------------------'_-- --------------------- ----------------------- - ------------ ----
No....*Y71_........ FEE:._ . ..........
THE COMMONWEALTH OF MASSACHUSETTS ,
r BOARD OF HEALTH
. ..........OF.......S;; ..�.. .
Application for Biiiposttf Works Tonstrurtion Vrrutit
Application is hereby made fora Permit to Construcf�( ) or-Repair) an Individual Sewage Disposal
System at
....
v� Location Address or Lot No.
-----------------
•' ~ O ner o m Address
Address
V Typof
eDweB11in1dingNo. of Bedrooms__________________ ______________________Ex arision Attic Size Lot__-_..._._.___..._..________Sq. feet
a g— p ( ) F Garbage Grinder. ( )
p-, Other—Type of Building ____________________________ No.-:of"persons.- __.._, ...........:__._..___. Showers ( ) — Cafeteria ( )
Other fixtures ..................................................
WDesign Flow........_...................._..............gallons per .peIrson per"day. Total daily low--------------------------------------------gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width--------__----- Diameter---------------- Depth----------------
x Disposal Trench—Nd._____________________ Width..................... Total.Length..............._---- Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter____________________ Depth below inlet____________________ Total leaching area------------------sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed.by----------------- ----------............................................... Date----------------
-----------------------
M Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water------------------------
(4 Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water-__-___________________-
---•--•----------------•----_..---------•.-•--------------•--•-•-------•--•-•----•----.._......_._.........................................................
0 Description of Soil.............................................................................................................-----------------------------------------------------------
x
U
-------------------------- - ---
U Na ure of Repai ms,o/yr j,lteratio�ns Answer when applicable � "'¢L� �� /ti e,0
'---,-.-�•"a-;..�`-------- -----
Af reement
The yur&fsi'gned-agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance•has been,issued.by the board of health.
ZZ
6.
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t F f ate y
Application Approved By..... t� = ........................... -- . . to f-----
Application Disapproved for the following reasons_________________
Z-------------------------------------•------•-•-•-••--------.-.----�`...................
;� Date
PermitNo........................................................... Issued--------------------------=-------=-----------=-•-------Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
.......... ...OF...... .. �.....a .....-.......-......-................
vEntifiratr of Tompliaurr
THIkIS CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
b
4-
at L' G-- ----- -- ----------- --- -� - . - - ----- :- --- 4Coe ------------------ -----has been insta ed in accordance with th rovisions of Article , o The State Itary s described in the
application for Disposal Works Constru tign Permit No.: .....
dated ........................7 -------_----• .
THE ISSUANCE OF THIS_,CERTIFICATE SHALL NOT.BE.CON ED AS'A'GUARANT,EE'TFlAT THE
SYSTEM W11- TUNCT@ON- SATISFACTORY.
DATE' ..... ...................................... Inspector ---- ----------------•--- -------- -------..__...--••---
THE COMMONWEALTH OF MASSACHUSETTS
.BOARD OF EALTH
uy A
/ (�.................... OF
/ .....-.. .....
No. ._._........... FEE_ .............-...
19ilipolial r tr rtio oamit
L
Permission is hereby granted
---- --•--•-- . . •-- ... -•-••• --------------------• f `
dividua wa ste
to Conat N st�t t'( Repa . ] l �--/` 1 ------
- St 3 7'�
as shown on the application for D osal .Works Construction P m No. __. ated_______-_ ..
F -b
-17------------------------
R w• Board-of'Hea
DATE:__ .
-FORM 1255' HOSBS &'wARREN7`INC.! PUBLISHERS -
r
y-
Ld,�CATlON SEWAGE PERMIT NO.
VILLAGE
INSTA LLER'S NAME & ADDRESS
GOB. ./�DN « iYTtrel//�/- IyIArs
BUILDER OR OWNER
i
DATE PERMIT ISSUED 77
DATE COMPLIANCE ISSUED 6 .2,317
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N0......1.. F>c$..... ,...00.......
THE COMMONWEALTH OF'MASSACHUSETTS
BOARD OF - HEALTH �
.. ..... . .... Town.. .....OF....Barnstable ......................
Appliratiun -fur Uiupuuttl Workfi Tomi#rurttuu Prruift '
Application.is hereby'made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at:
ti
---20?+._M tchell!s•-•Way----------------------------------------
Location-Address or Lot No.
................ry--Walton-----------••------------------------------•----•-----.... ------Hyannis
---
caner Address
w Jcseph P. Macom er & Son Inc . Centerville,
............. ....................................................---------••-•-•-------------
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms___________________ .Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------_------------------ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
P4 Other -fixtures
W Design Flow............................................gallons per person per day. Total daily flow-----------------.-----------------------.....gallons.
WSeptic Tank—Liquid capacity------------gallons Length:............... Width-------- ........ Diameter-----.---------- Depth----.-----------
x Disposal Trench—No..................... Width-_--___._..--.__-_-- Total Length.................... Total leaching area-------.------------sq. ft.
Seepage Pit No:................... Diameter.................... Depth below inlet.................... Total leaching area-------.----------sq. ft. c
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---•-----------------------------------
a Test Pit No. 1....._----------minutes per inch Depth of Test Pit_.._____-,__--_____. Depth to ground water...---.__-__._-,__...-.
f� Test Pit No. 2................minutes per inch -Depth of Test Pit..................... Depth to ground water_-.-.-._--__-'..___----.
W --------------------------------------------------------------------------------------------••---------------------------------------------------------------
O Description of.soil-------Sand & .Gravel
V ------------------------------------------------------------------------•---------------------------------------------------------------------------•-------------------------
W
V Nature of Repairs or Alterations—Answer when applicable.-..1-1000 gallon pit .overflow)_......
-------------------------------------------------------------------------------------------------------- ---------------------------------------------------------------------- -----------------
Agreement:
The undersigned agrees to install the aforedeseribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b ss XG b V
oar o ealth.
Sig Vey ki,, 11
.• . •-• ----- -------------------------•---_-••-- ._.. -- -
ate
Application Approved BY --------------- 1�= -�- � 7
Date
Application Disapproved for the following reasons:---••--•---•-•-------•-------------------------•-----------------_-..---------------------------------••--------
.............................•------.._..--------•------------•--.....----------•-------------•----............------•------------------------------------•-••---•----------------------------------
Date
PermitNo........................................................ Issued........................................................
Date
C;71'
No.........................
Fmc...................'.......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
........ .. .....
pfiration -fur IMlivuiitt1 Workii Tuu,itrurtiutt Prrutit
Application is hereby'made for a Permit to Construct ( ) or Repair (,;) an Individual Sewage Disposal
System at: " -
Location_Address or Lot No.
e
Owner sP Address
----•=. -----= -- ------------- -------------------- ---=--_----- --••--------....------•-•--•--•--------•---••••---
= •-•• - .
a Installer Address
UType of-Building Size Lot____________________________Sq. feet
Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
a4 Other—Type of Building ---------------------------- No. of persons__-__---_-__-___-_-..______ Showers ( ) — Cafeteria ( )
Q' Other fixtures
W Design Flow..........................._---------------_gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length-------_------- Width--------.------- Diameter----------.----- Depth..--------------
x Disposal Trench—No_ ____________________ Width_____-----_.--_--.-_ Total Length-------------------- Total leaching area..-_..___-___--____sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet_-_-_...____________ Total leaching area------------------sq. ft.
Z Other Distribution box ( y, Dosing tank ( )
aPercolation Test Results` Performed by--------------------- ---------------------------------------------------- Date--------- ----------•-•----------------
Test Pit No. 1______5______._minutes per inch Depth of Test Pit.................... Depth to ground water_---------_--..-_.___..
!1 Test Pit No. 2-----_----------minutes per inch Depth of Test Pit..-_--_-_-____.-__-_ Depth to ground water...------------------
I\I Y
________________________-----------------------------------------------------------------------------------
D Description of Soil--- `- '
x
U ---------------------------------------------------------....................................................................... -----------------------------------------------------------------------
W
x --------------`-------------------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable._-I--�:_....__._.__.__.':_..� �_�.t.._...r_) -max'-_.',,;___)
_-..-_------••---•----•-••-•----------------------------•-----------------------•--•--.__----------------•-•-•-•------------•-----
Agreement:y'
The.,a.undersigned agrees to install the aforedescfibed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary.Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the,,board:of,health.
---------------------------------- -------------------------- ------ -----------------------
P ,/ D to
Application Approved BY---- .. . � � <!-- -��-- -� --7-
- :..Date
Application Disapproved for the following reasons:..................---_--------------_-__.---__-_-------_--------.--------•---------_____. .___._________
................••-----••-................................................................................................. •----•---•--•-----------•-- ------------------------------------------ ......
Date
PermitNo....................................... Issued........................................................
- - - - - - - Date
THE COMMONWEALTH OF MASSACHUSETTS
F BOARD OF HEALTH
Ale
t,
w. rrtifiraV of f111utplittturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired O
- Installer 1
{
at----------- ----•----•_-- n?__: 1 � n --e i,.t ti(Jiw
--•--------•--
has been installed in accordance with the provisions of A of The State Sanitary Coe as describj id the
application for Disposal Works Construction Permit No__ _______________ _ _______ dated.... -----------------------------_____...
THE ISSUANCE OF THIS CERTIFICATE SHALL�NOT BE CONSTRUED AS A GUARANTEE THAT THE
M WILL FUNCTION SATISFACTORY.
DATI ..__ T
SYSTEM ,
___---- U_?U -----•-� -------•- Inspector .._,
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
61;7,r .....................r?`....... ... .OF.... ^+' Est a : .........
NO.----von• '''~--•-----•- .... FEE-•-•- ...............')rl
�i��u�ttt .�rk,� �utt�trurtiutt �rrutit
Permission is hereby granted ` 'O..J E sc 1-:..
to-Construct ( ) or Repair ( J�)� an Individual Sewage Disposal System
at No.... r; .,1 1 + " • ) " a on
............................................................ -----------------------------------------------------------------
`;2 7
as shown on the application for Disposal Works Construction Perml _____ _________________________________
ted
' � � ^, Board of Health
DATE........ "r-- --------- ..............................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS `�;•, ,
THE COMMONWEALTH OF MASSACHUSETTS
06k) 1w -- ----_--_OF...Ya.-FIUH .. ... ......................
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
Address or Lot No.
ess
Uisyosa Trench—No. .................... YVudtb----_--' Iotu Length-------------------- Total leacbin&arcx------'-sq. f t.
Seepage Pit lNu'--_-__- Diameter-------------------- Dcn16 below inlet.................... Total area------------------sq. 6.
Z Other Distribution box ( ) Dosing tank ( )
�_A vu ��n^
Percolation TestResults Performed bv_-----. `� �g ^�~^ -. Dxt�.--_---_.----_--
� Test 2d No. L-_--_.minutes per inch Depth of Test Pit--------"....... 6roth to ground water------------------------
� Test Pit No. inch
0 Description of Soil---...—---' -.-----------------'---''-----'
_-----......................................................................................................................................................................................... �
| ~~ -------'-'------'— '----''--''----'--------'---'-------'-
Nature of Repairs or Alterations--Answer when -_--_----__'-_-_----.--------_-- �
____'--_''-_----_.----_--'-- ___-_----_-_--_--'_''--.---.---.---_--
� /1gceeoeot: .
The undersigned agrees to install the afore6escribed Individual Sewage Disposal System in accordance with
the provisions of Article XIof the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ioanul o66���6
kj
' ^ �~-
--'
------- ---------'----
--
/*yyuraru?o Approved By-.- -~ -_
Application 1)isapyrovcd /m' thefollowing reasons:................................................................................................................
.........................................................................................................................................................................................................
' Date
Permit^~
| ' at
^---~------'-------------------- ------ ---------------------------------------------------' ' ------ -----'-
r
No.. --- • Fmic ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,PF HEA; T
A"
1 .. �... ... t ..--....OF... t_. .. '
,,. .. ---.........
.
Appliration for Bispmal i9orho Tomitrurtiou jJamit
Application is'hereby made for a Permit to Construct ( ') or Repair ( ) an Individual Sewage Disposal
System at - >
Li
Logati Address r or Lot No.
l
&' V
Address
W ._. U� l3I�q+'X?3tl' ta•9,_q`^'v ____ r�br`" .,_�3>....................................
T staller Address
Q Type of Building. Size Lot____________________________Sq. feet
U �'
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
P4 Other—T e of Building No: of persons............................ Showers — Cafeteria
al Other fixtures -------------------.............................
W Design Flow.........................................:..gallons per person per;day. Total daily flow--------------------------------------------gallons:,
WSeptic Tank—Liquid capacity------------gallons Length................ Width---------------- Diameter---------------- Depth---.-_-__--_-.-
x Disposal Trench—No..................... Width-------------------- Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by------------= ...... Date
W Test Pit No. 1................Minutes per inch Depth of Test Pit---:_:_:___......... Depth to ground water_..-------.--_-__----.-.
(� Test Pit No. 2................minutes per inch Depth of Test Pit..................._ Depth to ground water_--___-_--_-______-_-._.
a' ---•----------------------------------•=f------------------------------•----- ................................................................................
ODescription of Soil................................................................................................-------------------------------------------------•--------- -------
x ----------------------------------------------------------------------- ------------•------------------•---------------------------------
W
----------------------------------------------------------------------------------------
U Nature of-Repairs or Alterations—Answer when applicable-------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------•-----•---------.-_---------------------------------------------------------------------------------------------------
Agreenient:
The undersigned agrees to install_the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article YI of'the•Staie Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed...................................................................................... --------------------------------
Date
Application Approved BY---------------------------------------•-------------------•-----------------
Date
Application Disapproved for the following reasons--------------------------------•----------------------------................... ----------------------- -----
------------------------------------------------------------•--••-------•---------------•-----••--•-----------•----•-----•----------------------•--------•-----•------ --------------------------------
Da te -
Permit No. Issued !-------
° Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
q
..
a^
Tufffiratr of Toutp aurr.
'T S I TO CERTI ', That the Individual Sewage Disposal System constructed 1; ) or,Repaired ( )
l •h.
by
�n Installer t
+� 8
vim:& s � �. y .x•. ' -r:9 „r,�,y P.
at .Yf._ •q•---•---.° _-__-__i2 -t-.E�^✓ __ _______ .._ _ ._.� b,. _ _ _ ______
has teen installed in accordance with the provisions of Article.XI of The ate Sanitary Code as desf rlbed in the
application for Disposal Works Construction Permit No..................... 4............ dated "P`
THE ISSUANCE OF THIS CERTIFICATE SIHALL NOT BE CONSTRUED AS A G ARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY
r Po
DATE-- ----F-e •" -:�:� .....................------ Inspector------- r r .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O `'" IEALTH {,
A t '. .� ., ` s'......'O F............. ..
No. n --•---.... FE> _- .................
U apefi 1 N `i� `�l�r� tr rtilvn rr ti
Permissionx isehereby granted.-•-- .'_ 1 A 0.......................................................................
to Constr � ) or Repair .raft India Idual fA ewage Dts!oral :System y/
NO._ �,. .........� .�%.' •;-v, �` e � i+' .=................�'e✓' '---- ° -------------------------------------------------------
at - --•----!, Street
as shown on the application for Disposal Works,Construction'Permit Noy .: t ___ Dated._.�!_.a-�r, 7
r' --.-
4 ., . Bo :rt
�¢ F� � � � >• ard�of
DATE............ ��•------ -.:._... ---------------------- t,
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS