HomeMy WebLinkAbout0265 MITCHELL'S WAY - Health 265 Mitchell's Way
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TOWN OF BARNSTABLE ryrye�,,
LOCATION I / SEWAGE#ZO "V
VILLAGE ASSESSOR'S MAP&PARCEL ��-
INSTALLER'S NAME&PHONE Nq ' , ,�IZ6L���'
SEPTIC TANK CAPACITY /52�O Aq d4e0,1,,S
LEACHING FACILITY: (type) /2�%t (size)
NO.OF BED OOMS
OWNER .0
PERMIT DATE: !I COMPLIANCE DATE: sl 3
Separation Distance Between the:
Maximum Adjusted Groundwater T le o the Bottom of Leaching Facility Feet
Private Water Supply Well, Vhincility(If any wells exist on
site or within 200 feetility) Feet
Edge of Wetland and Leac any wetlands exist within
300 feet of leach' a Feet
FURNISHED BY 4
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No. Fee /
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Z/
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for disposal fps m Con=ystem
n Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( Abandon( ) ❑Individual Components
Location Address or Lot No. j>j7-7
Ow s Name Addre 1.
Assessor's Map/Parcel C'S � (.�n/� &�'
Installer's Name,Address,and Tel.No. Designer's Name,Address, d Tel. 9.
0+E01044C, ON-- -013 V20 ol's
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.require ) . gpd Design flow provided ��: gpd
Plan Date �? �I Number of sheets Revision Date
Title
Size of Septic Tank 15 co(� _� Type of S.A. ` t4o
Description of Soil _C75) J
Nature of Repairs or Alterations(Answ r when applic leIFS
)
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 op ation until a Certificate of
Compliance has been issued by this Board o a .
Sig Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. 20 0? Date Issued 3
No. (7 `tl / � e Fee U
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:_
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZfptJfication for Misposal *pot to Construction 3permit
Application for a Permit to Construct( ) Repair( ) Upgrade(V) Abandon( ) omplete System ❑Individual Components
Location Address or Lot No. ,�Z, �. Owner's Name Address and Tel
Assessor's Map/Parcel . 041AjAAt1j
Gb`
Installer's Name,Address,and Tel.14o. Designer's Name,Address,and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.fr. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
t _
Other Fixtures
Design Flow(min.require ) �. *' gpd Design flow provided �. a � gpd
Plan Date Number of sheets Revision Date
t Title
Size of Septic Tank
p 15~Q Type of S.A.
Description-of Soil
Nature of Repairs or Alterations(Answer when applic ble)
� ,tyjs
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 inRopation until a Certificate of
Compliance has been issued by this Board of
Sign Date
Application Approved by Date17
v
Application Disapproved by Date
for the following reasons yy-
. i
Permit No. .2c) C'J 075 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,
,t�that
tt�the On,-site Sewage Disposal system Constructed( Repaired( ) Upgraded
Abandoned( )by �P'if 1(.1./� p�'f \✓ �.. b
at has been constructed in accordance
.with the provisions of Title 5 and the for Disposal Sys ern Construction Permit No. v/ —D 71 dated
Installer t Designer
#bedrooms Approved design flow n gpd
The issuance of this p it sh!11 riot be construed as a guarantee that the system will ctid as designed.
Date 1 [ Inspector" / ( , 1
-------------------------t-------`------------=--------------------------------- ------------------------------------------------
No. / /) �1 Fee /UG
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Disposal 6pstent Construction -rrrnut
Permission is hereby granted to Construct( ) Repair( ) Upgrade( Abandon( )
System located at SO
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:Construction must be completed within three years of the date of this permit.
Date Approved by l n r
� ,/ _
r '
Town of Barnstable
Regulatory Services
Thomas F. Geiler,Director
' Public Health Division `
Thomas McKean,Director r
200 Main Street, Hyannis,MA 02601
Office:, 508- 62- 644 w Fax: 508 790-6304
Date:J 3 zoi9 Sewage Permit# Assessor's Map/Parcel
Installer& Designer-Certification Form
Designer: �� `"<<-"�G/�� �"�4 Installer: �Q��i✓t��
Address: ��4' A4x 71; Address: �- y A X6,
On , l/ was issued a permit to install a
( at ) (installer)-
septic stem at i'`/ �'�TY' ''�''Wi,r
P Y / based on a design drawn by
(address)
4 dated
/ (designer)
(/ I certify that the septic system referenced above was installed substantial) accordingto
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State & Local Regulations. Plan revision or
cert" ied as- ilt by designer to follow. Stripout(if required) was inspected and the soils
we fo d s isfactory.
TERENCE
M ^a
er' g ature WAYS
0179
.� nSTE.r
(Designer's igna e) (Affix DeWg tamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE'
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
gAoffice formsWesignercertification form.doc _
' 7
Town of Barnstable` P#
' Department of Regulatory Services
Public:Hea'Ith Division Date. / V � a
aajq �� 200 Main Street,Hyannis MA 02601
j / f
Date Scheduled / G Time Fee Pd. Opel
t. Soil Suitability;Assessment for S age Disposal
s'
Performed By: ' �✓/ c�b� Witnessed By: -
ioation"aaaress 265 Mltcl�ell's Way owns='sxame Ron"t�Cote Jr.
Hyannis 265,Mitchell's'Way
Address Hyannis, MA 02601
Assessor's Map/Parcel: 290/.�07 Engineer's Name Sweetser Engineering
NEW CONSTRUCTION- REPAIR X Telephone# 508-385-6900
Land Use-'- Slopes N 60 - Surface Stones
All
Distances from: Open Water Body y- _ ft Possible Wet Area� /°ft Drinking Water Well ft
Drainage Way ft Property Line ft Other �ft
SKETCH:(Street name,dimensions of dot,exact locations of test holes&perc tests,locate wetlands in proximity to holes)
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° `Parent materi r Bolo c" UT De th to-Bedrock
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Dep Groundwater Standing Water m Hole: Weeping from Pit Face
tEstrmated'y,SeasonalI�gh�Groundwater 1, Ii!i
✓ n.�,�t Ft7"3. `� .'°'xtsxibF � usn' -' n i" •r a a� F t ;r"3
z 1aMCt}fOd USed + k? a 9 9 }
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,Depth toweepmg fiom srde'of ob rho gym' rGroundwater Ad�ushpent
i Index1We11#;1 ReaduigrDate k IIld W '4 b ° t ex ell levelirrt aAd�{factor, w tiAd�S GroundwaterLevelx t
{,',f ^! trw
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s� "• '`�' 7 �'�tyyxdap ", ,:tea t�*4... °ay' -r "&u ` .. ;� s:yy y, c 'r' ':!:�1"�r' a'A7a'.�,1,
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* 3Depth of Per'c' Z i Time at 6"
t N F' { {
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1 start Pie soak T�me;Q Time(9 -`6-)
P y
Rate Mui/Inchit� G f f s
p S to Siirtabili Assessment Site Passed ( $ "ty f i lc Srte Failed i Additional Testing Needed(Y/I f
,� a ry,� ua �: �. ,��b a � ✓ r ` YI
r org,nal`Putilrc HealthIhv,sron . Observatton);HolesData To Be Completed oniBack, n
.x .�,•xg�k4�e�`I ,a~a � � `�rx� �%��, ,: i �sn�;"k, .� slF �t ..;r;wxl� $,.. �sf+ #a�.
>If;percolahotest�to,be conductedw><tWn100 ofwetlandyou mus>b first uot�fythe
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Q;\SEPTICIPERCFORM
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Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
C nsi enc %Gravel) 1
O �p PA A14 TS
> LEY o �� <
L � xY 4�.� �j,�]�'+�-cf w�z�'�,S S � �rr� a,� �'.5 t a N�)�: err r' pa rJr1r -s ig t'a�' � ✓t r- �
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Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency,%Gravel
r;—Z 7
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Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Gravel)
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Depth from Soil'Horizori` ' Soil Texture Soil Color Soil Other
Surface'(in.) i (USDA) (Munsell) Mottling (Structure Stones Boulders.
Consistency:%Graver
s Flo0M k. surance Rate=Ma
Above 500 year flood'bouii �' No Yes
,.
Within 500 year boundary I No t/ Yes
Within l0U year', bound' No Yes
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�t +De tfi of�Na mall car" ervaoustllZati nal
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Doost leastfour feetofna l y occturtng pervious matertal`exist in all areas observed ttuoughout the
anew, p four the soil abs tons stems
If hat is the depfih o *ia I ttu y:occurririg p I. OUS material?,,
=, -
Ceitificafiion i
I ee{ that on ` -:5 # N (date)I have passed.the soillevalualor examination approved bylttie ;
{Depart�aent ofnviyonutental otection and'that above analysis was performed:byime consistent with.
r 't ty{ t a ,�y Sir'`.-a la ti, i$f1 e„ u r y ,re m ,r i }3'.g '+t 4�,� ,
therc-lyI
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juu�d�tra ;ecp $use d expe enc µ Cr CMR 15.017:
b "h+{- t4 Y {,
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s i, ,r'„ Date l 1 Signattue ,;1�� ., : . ,
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Q 1SEPTICIPERCFORMDOC tg 1 s
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IKE Town of Barnstable Barnstable
Inspectional Services wiCaM
v BARNSMAOM
9� * ,� Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas A.McKean,CHO
FAX: 508-790-6304
CERTIFIED MAIL##7015 1730 0001 4989 0427
December 28, 2018
COTE, RONALD O JR& CUMMINGS, CONNOR P
265 MITCHELL'S WAY
HYANNIS, MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 265 Mitchells Way, Hyannis, MA was inspected on
12/14/2018 by Brett Hickey, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Cesspool is structurally unsound.
You are ordered to repair or replace the septic system within six (6) months 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
Th as McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\265 Mitchells Way Hyannis.doc
Town of Barnstable
MAM* snuvsr�sce,
, ' Regulatory Services Department
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
--o 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
❑ Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation
of 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
Commonwealth of Massachusetts
�m Title 5 Official Inspection .Form -
I1
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments „;;,
(� _J
�
265 Mitchells Wa fi•cL ,� Y K
v�
Property Address I
Ronald Cote Co
Owner Owner's Name
; ,.
required for every
information is Hyannis. j Ma 02601 12-14-18
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return
key. � Company Name
374 Route 130
�1 Company Address ,.
Sandwich Ma 02563
City/Town State Zip Code
rxn (508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported.below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined `
that the system:
1. { ❑ Passes e
2. ❑ Conditionally Passes
3.• ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑■ Fails
Brett Hickey r' �wo.W a��
m.r��,:e,.� .�. �s.
12-14-18
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow'of.
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The.original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note:This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
c Commonwealth of Massachusetts
�d Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I;
u 265 Mitchells Way
Property Address
Ronald Cote
Owner Owner's Name
information is Hyannis Ma 02601 12-14-18
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes: .
t
❑ 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:
System fails due to a cesspool being structurally unsound as per conversation with Board
of Health agent on 12-18-18. See attached picture showing open cover as well as
a hole along side of cesspool that's beginning to cave in.
2) System Conditionally Passes:
❑ One or more system compone-its 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 wi I 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 cf 18
Commonwealth of Massachusetts `
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
265 Mitchells Way
Property Address
Ronald Cote '
Owner Owner's Name
information is Hyannis Ma 02601 12-14-18
required for every y
page. City/Town State Zip'Code Date of Inspection
-C. Inspection Summary (cont.) k ;
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
4 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):
. t.
❑ obstruction is-removed `❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑. Y ❑ N ❑ ND(Explain below):
El The system required pumping more than 4 times a year due to broken or obstructed pipe(s).Thee
system will pass inspection if(with approval of the Board of Health):
y
❑ 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:
=R ❑ 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
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c / 265 Mitchells Way
u
Property Address
Ronald Cote
Owner Owner's Name
information is Hyannis Ma 02601 12-14-18
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is withii 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 tan', 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
❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Ins ec Fo
rm
F m
I� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
265 Mitchells Way
Property Address
Ronald Cote -
Owner Owner's Name
information is Hyannis Ma 02601 12-14-18
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to.All Systems: (cont.)
Yes No E
Static liquid level in the"distribution box above outlet invert due to an overloaded,
❑ or clogged SAS or cesspool
0 Q Liquid depth in cesspool is less than 6"below invert or available volume is less
than '/2 day flow .. .
❑ El Required pumping more than 4 times in the last.year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ 0 Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply
-well. ,
,4
❑ 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
r
❑ ❑ 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.]
❑. ElThe system is a cesspool serving a facility with a design flow of 2000 gpd-
Y , 10,000 gpd.
a ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system ownershould 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:.
ry For large systems, you must indicate either"y`es—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
El El Area
system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
z t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
�. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
265 Mitchells Way
u
Property Address
Ronald Cote
Owner Owner's Name
information is Hyannis Ma 02601 12-14-18
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for all inspections:
Yes No
El ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ El Were any of the:system components pumped out in the previous two weeks?
El ❑ Has the system received normal flows in the previous two week period?
❑ a Have large volumes of water been introduced to the system recently or as part of
this inspection?
O ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ El Was the facility or dwelling inspected for signs of sewage back up?
0 ❑ Was the site inspected for signs of break out?
0 ❑ Were all system components, excluding the SAS, located on site?
El ❑ Were the septi: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?
❑ El 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:
❑ El 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.712612018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
265 Mitchells Way
Property Address
Ronald Cote
Owner Owner's Name
information is required for every -Hyannis annis ,Ma 02601 12-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
no design plans 2
Number of bedrooms(design): Number of bedrooms(actual):
- NA
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
2
Number of current residents:
Does residence have a garbage grinder?• ❑ Yes El No
Does residence have a water treatment unit? ❑ Yes rol No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection .
information in this report.) El Yes 0. No
Laundry system inspected? ❑ Yes RI No
Seasonal use? ❑ Yes Q No
See below
Water meter readings, if available(last 2 years usage'(gpd)):
Detail:
***2018-'29,172gallons 2017-15,708gallons***
Sump pump? ❑ Yes ❑E No -
Last date of occupancy: Current
, Date
t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
,ip Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
265 Mitchells Way
u�
Property Address
Ronald Cote
Owner Owner's Name
information is Hyannis Ma 02601 12-14-18
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
2. Commercial/Industrial Flow Conditions:
NA
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/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: Owner- last pumped Oct. 2018
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
c Commonwealth of Massachusetts
Title 5 Official Inspection Form ;
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-` 265 Mitchells Way
Property Address
Ronald Cote
Owner Owner's Name
information is Hyannis Ma 02601 12-14-18
required for every y
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 s
❑ 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.
n Other(describe):
Two cesspools in series
Approximate age of all components, date installed (if.known)and source of information:
unknown due to lack of record ;
t f '
Were sewage odors detected when arriving'at the site? ❑ Yes ❑■ No
5. Building Sewer(locate on site plan): '
` 21
Depth below grade: feet
Material of construction:
❑40 PVC orangeburg
. ❑ cast iron ❑� other(explain): •
Town water
Distance from private water supply well or suction line: feet
Comments(on condition of joints, "venting, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts -
i , Title 5 Official Inspection Form
j� I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r
265 Mitchells Way
Property Address
Ronald Cote
Owner Owner's Name
information is Hyannis Ma 02601 12-14-18
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate or Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
M Title 5 Official Inspection Form
5 Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
&"P
265 Mitchells Way
�V
Property Address
Ronald Cote
Owner Owners Name
information is Hyannis Ma 02601 12-14-18
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
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):
' NA
Depth below grade:
Material ofconstruction: ,
❑ 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
265 Mitchells Way
Property Address
Ronald Cote
Owner Owner's Name
information is Hyannis Ma 02601 12-14-18
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and foat 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):
NA
Depth of liquid level above outlet irvert
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.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts '
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
265 Mitchells Way "
Property Address „
Ronald Cote
Owner Owner's Name
information is Hyannis Ma 02601 12-14-18
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
}4
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes No* k
Alarms in working order: ❑ Yes 0 No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA r.
* 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:
❑ leaching chambers number:
❑ x . leaching galleries number:
leaching trenches number, length:
❑ leaching fields number, dimensions:
1 overflow(2 total)
overflow cesspool number:
P
❑ innovative/alternative system
Type/name of technology:
,+ t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
265 Mitchells Way
Property Address
Ronald Cote
Owner Owner's Name
information is Hyannis Ma 02601 12-14-18
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
2 in series
Number and configuration
Depth—top of liquid to inlet invert 8" (overflow was dry)
10"
Depth of solids layer
311
Depth of scum layer
6'x8'
Dimensions of cesspool
block
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.):
See attached picture. Cesspool has heavy root growth and is in poor structural condition.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1L of 18
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
265 Mitchells Way ,
L
Property Address -
Ronald Cote
Owner Owner's Name
information is Hyannis Ma 02601 12-14-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
NA -
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): "
t5insp.doc•rev.726/2018 { Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
i
c Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
265 Mitchells Way
Property Address
Ronald Cote
Owner Owner's Name
information is Hyannis Ma 02601 12-14-18
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑E hand-sketch in the area below
❑ drawing attached separately
A B
Al-41'
B1.5W
1 Driveway
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1E of 18
L
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
265 Mitchells Way 4
u
Property Address
Ronald Cote
Owner Owner's Name
information is required for every -Hyannis annis Ma, 02601 12-14-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) -
15. Site Exam: '
■❑ Check Slope
❑N Surface water
❑■ Check cellar
❑� Shallow wells
Estimated depth to high ground water. _ :: No GW 5' below SAS
. �� � .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
El .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:
A previous inspection report shows no ground water 5' below SAS
! 5
t Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
R
Commonwealth of Massachusetts
�A ,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
265 Mitchells Way
Property Address
Ronald Cote
Owner Owner's Name
information is Hyannis Ma 02601 12-14-18
required for every y
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
M A. Inspector Information: Complete all fields in this section.
FM B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
❑M 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
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Commonwealth of Massachusetts `�90r/l)�
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 265 Mitchells Way
Property Address
Dennis &Vicky Marchant
Owner Owner's Name
information is Hyannis Ma 02601 9-20-16
required for every Y
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information �''# 93
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Brett Hickey
use the return
Name of Inspector
key.
B&B Excavation
r� Company Name
374 Route 130 t
Company Address
Sandwich Ma 02563
City/Town State Zip Code
(508)477-0653 SI 13747
Telephone Number License Number ;
B. Certification
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
9-20-16
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.
****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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;.0 265 Mitchells Way
Property Address
Dennis&Vicky M{archant
Owner Owner's Name
information is required for every Hyannis Ma 02601 9-20-16
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or EJ always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System consists of 2 cesspools in series and was in working order at time of inspection. Cesspool
was pumped when inspected.
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):
t
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
N 265 Mitchells Way
Property Address
Dennis&Vicky Marchant
Owner Owner's Name
information is required for every Hyannis Ma 02601 9-20-16
_
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�.w 265 Mitchells Way
Property Address
Dennis&Vicky Marchant
Owner Owner's Name
information is Hyannis Ma 02601 9-20-16
required for every y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the-SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
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
❑ 0 Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
265 Mitchells Way
Property Address
Dennis &Vicky Marchant
Owner Owner's Name
information is
required for every Hyannis i Ma 02601 9-20-16
page. City/Town e 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:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For you,stems large s must indicate either"yes" or"no"to each of the following,
g y y y g, in addition to the
questions in Section,D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
.a
❑ ❑ 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 iDepartment.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 265 Mitchells Way
Property Address
Dennis&Vicky Marchant
Owner Owner's Name
information is required for every Hyannis Ma 02601 9-20-16
page. City/Town State Zip Code Date of Inspection
'C. Checklist 4
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ 0 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)]
D. System Information
f
Residential Flow Conditions:
Number of bedrooms(design): No design Number of bedrooms (Actual) 2
plans
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA
t5ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 265 Mitchells Way
Property Address
Dennis &Vicky Marchant
Owner Owner's Name
information is required for every Hyannis Ma 02601 9-20-16
_
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? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ' ❑ Yes ® No
Water meter readings, if available last 2 ears usage d See below
9 ( Y 9 (gp ))�
Detail
2014-22,500gallons 2015-15,000gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: August 2016
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
NA
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° 265 Mitchells Way
Property Address
Dennis &Vicky Marchant
Owner Owner's Name
information is required for every Hyannis Ma 02601 9-20-16
page. Cityfrown 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: Owner- last pump unknown
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? Sight glasses on pump truck
Reason for pumping: Cesspools must be pumped for inspection
Type of System:
❑ Septic tank, distribution box, soil absorption system
® Single cesspool
® Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 265 Mitchells Way
Property Address
Dennis&Vicky Marchant
Owner Owner's Name
information is required for every Hyannis Ma 02601 9-20-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
No records due to age
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: NAfeet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 265 Mitchells Way
Property Address
Dennis &Vicky Marchant
Owner Owner's Name
information is required for every. Y Hyannis Ma 02601 9-20-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
I
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
4
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.):
Grease Trap (locate on site plan):
t NA
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
265 Mitchells Way
Property Address
Dennis&Vicky Marchant
Owner Owner's Name
information is required for every Hyannis Ma 02601 9-20-16
page. City/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: NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 265 Mitchells Way
Property Address
Dennis&Vicky Marchant
Owner Owner's Name
information is required for every Hyannis Ma . 02601 9-20-16
page. CityTTown 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 NA
P
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 workingiorder: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 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
^M 265 Mitchells Way
Property Address
Dennis &Vicky Marchant
Owner Owner's Name
information is
required for every Hyannis Ma 02601 9-20-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
® overflow cesspool number: (1) 6'x8'
❑ 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.):
Overflow cesspool was in working order at time of inspection:
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration 2 in series
Depth —top of liquid to inlet invert 3'6"
Depth of solids layer 7
Depth of scum layer 2
Dimensions of cesspool 6'x8'
Materials of construction Blocks
Indication of groundwater inflow ❑ Yes ® No
t5ins•3113 Title 5 Official Inspection Form: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 265 Mitchells Way
Property Address
Dennis &Vicky Marchant
Owner Owner's Name
information is Hyannis Ma 02601 9-20-16
required for every y _
page. Cityrrown 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: NA
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 265 Mitchells Way
Property Address
Dennis&Vicky Marchant
Owner Owner's Name
information is required for every Hyannis Ma 02601 9-20-16
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
#265
A _
Al-411
131-56*
MlTC-HtL,Vs':, AN
t5ins•3/13 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
265 Mitchells Way
Property Address
Dennis&Vicky Marchant
Owner Owner's Name
information is
required for every Hyannis Ma 02601 9-20-16
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: >15'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:
Perk tests from neighboring lot shows ground water Greater than 12'
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
There is a large drop off in the rear of the property greater than 5' below bottom of cesspool elevation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
e
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
q
265 Mitchells Way
Property Address
Dennis&Vicky Marchant
Owner Owner's Name
information is required for every Hyannis Ma 02601 9-20-16
page. City/Town 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
n
k
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
f
SOI
TOP OF FOUNDATION ; 20 FT. MINIMUM FROM CELLAR OR CRAWL SPACE � �
10 FT. MINIMUM FROM SLAB _�
DATE OF SOIL TEST JANUARY 17Q
ELEV. _ --- - 10 FT. MINIMUM
SOIL TEST DONE BY SWAT R P�•�
(ASSUMED) C I CLEAN SAND WITNESSED 8Y _jz, () M Ai 1
CONCRETE INSPECTION PORT -" '—
COVERS 4" SCHEDULE 40 PVC PIPE I LOAM AND SEED pp��///��ry HOLE
T MIN. PITCH 1/8" PER FT. '� 2" L4YER OF OBSERVATION ION HOLE 1 ELEV.-__98_'_
1/8" TO 1/2" PERCOLATION RATE <-2 MIN./INCH AT INCHES
' WASHED STONE
DEPTH HORiZ TEXTURE COLOR MOTT. OTHER
I OR FILTER FABRIC ANT 0-6" Ap LOAMY SANG t0YR5/1 NO FOOTS
3.00 I 4" CAST IRON PIPE ".60 MIN. NOT REQUIRED ���
(OR EQUAL) MINIMUM I
PITCH 1/4" PER FT. OW \ ! {
i TEE ��z I6-27" B LOAMY SAND 10YR6/6 ; }ROQ'S
l ('� LEVELERS 1
J i 127-126" iC COARSE SAND 2.5_Y7/4 �5F COBBLES
^----- I FLOW LINE r`—"I`----- - °i NO WATER ENCOUNTERED AT 126' ELEV. - 88EL .,
0..
"' 'MIN. ❑ OLc. ❑ ❑ O ❑ ❑ ❑ ❑ ❑ I
ELEV. ------ L—'_! 20 0 0 I o o SER ATI H 2 ELEV,=--98.6_
! — _ ZQ_ GA ELEV. — _95�50 ELEV. — _�'S_.33_ o f
BAFFLE 1 0 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 2' o DEPTH HOR1Z TEXTURE COLOR MO T T. OTHER I
I / i ,JIB Ml13 # nON 0 0 0 0 0 o j0-6" IAp LOAMY SAND 10YR5/1 NO ROOTS 1 I
} ELEV. _ ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑ ❑ ❑
t LIQUID OUTLET r I"—'-- l�r� _ Q_ 0 0 0 c o 0 0 ELEV. - 93.10- �6-27" B LOAMY SAND 10YR6/6 IROOTS
DEP4 F 14 INCHES H TEE (TO BE PLACED ON FIRM BASE) TO BE WATER TESTED 2 500 GALLON GALLEYS WITH 127-120" jC iCOARSE SAND �2.5Y7/4 15% COBBLES
5 FEET 19 INCHES 1 IF MORE THAN ONE OUTLET STONE IN AN 11
6 FEE` 24 INCHES 1500 GALLON . I NO WATER ENCOUNTERED AT _ 120" ELEV. = 88.6
7 FEET 29 INCHES (TO BE PLACED ON FIRM BASE) 13' X 25' X 2' TRENCH FORMATION � WELL N A +� -�-'--
8 FEET 34 INCHES SEPTIC TANK —'—""'� 3 00 ZONE
3/4" 1 1/2" CLEAN JSOIL ABS! P"noN 1, INDEX
DOUBLEE WASHED STONE ADJUST DESIGN I"A
1LCULA�ONS
FREE OF FINES & SILT SYSTEM 'SAS; { ,� NUMBER OF BEDROOMS 2
GARBAGE DISPOSAL UNIT
USGS PROBABLE WATER TABLE ELEV, = ------ TOTAL ESTIMATED FLOW _
SEWAGE DISPOSAL SYSTEM PRORLE OBSERVED WATER TABLE ( / / } ELEV. = ___� _ ( 110 GAL./SR./DAY X _„2.., OR.) GAL./DAY
NOT TO SCALE BOTTOM OF TEST HOLE ELEV, = REQUIRED SEPTIC TANK CAPACITY _ Q_ GAL.
ACTUAL SIZE OF SEPTIC TANK _1600. GAL.
I ' SOIL CLASSIFICATION
DESIGN PERCOLATION RATE <_'„� MIN./IN.
EFFLUENT LOADING RATE GAL./DAY/S.F.
_
I LEACHING AREA l?A SO. FT. i
(13X28)+(38X2X2) #
LEACHING C'APAC17Y (AREA X RATE) JUAl GAL./DAY
477.00 X 0.74
RESERVE LEACHING CAPACITY MW GAL./DAY
{ NOTE S:
I
1. ALL WORKMANSHIP AND MATERIALS SHALL CONFORM TO D.E.P.
t TITLE 5 AND THE TOWN'S RULES AND REGULATIONS FOR
{} TIHE SUBSURFACE DISPOSAL OF SEWAGE. I
2. ALL COVERS TO SANITARY UNITS SHALL BE BROUGHT TO
i WITHIN 6" OF FINISHED GRADE. i
3. ALL COMPONENTS OF THE SANITARY SYSTEM SHALL BE CAPABLE OF
WITHSTANDING H-10 LOADING UNLESS THEY ARE UNDER OR WITHIN
10 FT. OF DRIVES OR PARKING AREAS. H-20 LOADING SHALL BE
I I USED UNDER OR WITHIN 10 FT, OF DRIVES OR PARKING AREAS.
\ 4. ANY MASONARY UNITS USED TO BRING COVERS TO GRADE SHALL
BE MORTARED IN PLACE.
5. NO DETERMINATION HAS BEEN MADE AS TO COMPLIANCE WITH
m DEEDED OR ZONING REGULATIONS. OWNER / APPLICANT IS TO
" 98.9 98•4 OBTAIN SUCH DETERMINATION FROM APPROPRIATE AUTHORITY,
I S. fr T1L,7ES SHOWN ARE APPROXIMATE ONLY, EXCAVATION CONTRACTOR
IS TO CALL "DIG-SAFE" AT 1-888-344-7233 AT LEAST 72 HOURS
PRIOR TO COMMENCING WORK ON SITE. I
7. CONTRACTOR IS TO VERIFY GRADES AND ELEVATIONS AS WELL AS t
a SITE CONDITIONS PRIOR TO COMMENCING WORK ON SITE, ANY VARIATION
IS TO BE BROUGHT TO THE ATTENTION OF THE DESIGN ENGINEER
kd \ \i`_ 98.E IMMEDIATELY.
8. PARCEL IS IN FLOOD ZONE
f $ 9. + OT IS SHOWN ON ASSESSORS MAP _050- 1
_ AS PARCEL 07 _.
10. EXISTING CESSPOOLS ARE TO BE PUMPED AND BACKFILLED WITH SAND.
4 f �yg'2 13 00 11. THE INSTALLER IS TO GIVE THE ENGINEER A. MINIMUM OF 48 HOURS
38 1 (2 WORKING DAYS) NOTICE FOR THE FINAL INSPECTION (NUMBER BELOW).
.� R� 1500 GALLON
f r'' 99.1 ''` SEPTIC TANK $ `
1 . 98.0 D. ` 98.' 1I1
} 0' i
BOX 0 i0
nor 1s _
9
15,075.6 f 5 F �� ,p a
I °,. �8.9 , APPROVED: BOARD OF HEALTH
•�,,. SOIL TEST waR
.j
TEST 1 V
1 '
DATE AGENT
` F�`� tY t JIS 8. PROPOSED SEPTIC DESIGN
0 x
I FOR
/ f RON O. COTE JR.
i 265 MITCHELL'S WAY, LOT 15
HYANNIS, MASS.
l�. iNV VAJ s wm , IWG G
ji
203 SETUCKET ROAD
I ; MITCHELLS �MY � I
508— P. 0. BOX 713
SOUTH DENNIS, M ASS.LEGEND: 385-6900
02660 i
i EXISTING SPOT ELEVATION 0010
i ! EXISTING CONTOUR ----00---- j �� '�. C DATE y SCALE 1 " _ '
AN. 17 2019 — 20 FINAL SPOT ELEVATION v , J
i f FINAL CONTOUR
I SOIL TEST LOCATION I
I UTILITY POLE -0- REV. JOB NO.
TOWN WATER —W W�� t ! MAR. 8, 2019 8143--00
CATCH BASIN 0i
LOCA ; ION M A.
GAS LINE --- -----�
I CLEAN OUT C V I o REV. i SHEET 1 OF 1 I
I j CESSPOOL C.P. 0
C. SB PRG�r`814.3-471,dwg t814.3-SAS.D4V 0 2019 SWEETSER E' so;�E�::RING