HomeMy WebLinkAbout0353 MITCHELL'S WAY - Health 353 Mitchell-s`Wa M1t
Hyannis P
A = 291, 012 a _-
ax
E
BARNS
LOCATION 3S3 , �F�t�S SEWAGE #
VILLAGE )�66ts ASSESSOR'S MAP & LOT s19/" 0)
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY l^�
LEACHING FACILITY: (type)
NO.OF BEDROOMS 3
� BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater.Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site.or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leac ng facility) Feet
Furnished by 4t tTon
413. ol7
3 fly,4130
Commonwealth of Massachusetts
Title 5 Official Inspection Form
,M
Subsurface Sewage Disposai System rollm - Net fc Vciuntay assessments f_
-opery Address /
u v
Owner own"ers Name
rforradon s e
required for every A''�h� -- ✓T Qo�(o0 �� otQ
page. Cay;ii ovm ?^ Jate o ,nspecd r< r
Inspection results must be submitted on this fora. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
.
tmportant ngoLftforms n A- Inspector Info anon
filling out forms P
or,the computer, O
use only the tab A r h�
Kev to move Voui spec'„ r
Liar::e o:;�_ ��r;
cursor_do not
use the return
key. Company Name 0
m i Company Add-ess
AS G.✓7
Cry o �y :ate Zip Code
eieph ;;m0er _toe nse Number
B. Certification
certify that: ; am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); i have personally ir;spectec the sewage cispcsai system at the property address
iisted above;tre information reposed beiOw is true. accurate and complete as of the time of my
inspection: and the inspection was perermed based c..;;,y training and experience in the proper function
and maintenance cf on-site sewage disposai systems.Ater ccrcucting this inspection i have determines
`hat the syst
' Passes
L. i vvr OiuCndtIV `BSSe
3. Neecs =urther Evaivaticn by _ccai ,approving,Authority
nspec c:'s ignac r mat
The syster nspecter sraii subm:a :;c:y:f:n s nspectio .epos tc .he,approving Authority,Board
os Heaitr cr DEP)within 3C days of con?pieanc this .nspecticn. ,'the system has a design flour of
0.000 epd or create". i le "spec or anc one system owner <i!submit the report to the appropriate
regiona! ofice of the DEP. The orcr:ai torn should be sent tc:he system owner and copies sent to
' the buye-, E applicabie, and fne approving autncrity.
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.
ti:nsp.4oc-w.?i2s.-cC':S -..e 5 oa -speed,:rc.-,acscr."zce 3e..zye Z; xP—syster..-page:of?S
Commonwealth of Massachusetts
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Idl
Property Address
Owner G� N -Sv,
Owner's Name
information is i/ ��` �1 6 // a9
required for every A f1✓��.f /'� 10
page. City/Town State Zip Code Date of In
tpectil5n.
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) ;te asses:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
2) System Conditionally Passes:
One or more system components as described in the "Conditional Pass'section need to be
replaced or repaired.The system,upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes', "no or"not determined" (Y, N, ND)for the following statements. If"not
determined,' please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not)is structurally
unsound, exhibits substantial infiltration or 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 I N ❑ ND (Explain below):
t5insp.00c•rev.7262018 Title 5 Offiaa inspecao^=or,:Suosur.'ace sewage Dispose]System•?age 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
22C7
Property Address
�2r �sSo y
Owner Owner's Name
information is
required for every /ka A n +J 0.)60/ �l �p
page. City/Town State Zip Code Date of I n ecti
C. Inspection Summary (cost.)
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 ElNO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO (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.712612018 '.to 5 Ji`aal:rspecncn=o S nsuCace sewage:!isposai system-?age 3 0!16 .
Commonwealth of Massachusetts
F Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
�/ vt So 17
Owner Owner's Name
information is Alf 0. &q
required for every
page. City/Town State Zip Code Date of Insp ction
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
*`This system passes if the well water analysis; performed at a DEP certified laboratory;for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or
`s clogged SAS or cesspool
1= Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp-doe•rev.72612018 -itle 5 y`gai ns?ec':cn Fcrr.:Subsurface Sev ge Cispcsal System•Page<of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for V luntary Assessments
.�.5 �.
Property Address,
' �r c45 o vI
Owner Owner's Name
information is / / Qdc0 6 ��/40
required for every /7�tA01JI'V!(
page. City/Town State Zip Code Date of I spection
C. Inspection Summary (cone.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
J S tic liquid level in the distribution box above outlet invert due to an overoaded
or clogged SAS or cesspool
1- id depth in cesspool is less than 6" below invert or available volume is less
an '/z day flow
I� Required pumping more than 4 times in the last year NOT due to clogged or
bstructed pipe(s). Number of times pumped:
U I 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
-- i� well.
I Any portion of a cesspool or privy is within 50 feet of a private water suppiy well.
U !!� 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-
Ile`- 10,000 gpd.
r= 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 0.4.
Yes No
the'system is within 400 feet of a surface drinking water supply
71 17. 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
J Area-iWPA) or a mapped Zone 11 of a public water supply well
iSinsP Goc"ev.7262018 ?We 5 0a.Ins?ector=or.::Suosu-a:e Sewage tis?osaj System•Gage 5 o`18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Volunt ry Assessments
3S3 /111 C/ 11...r (,la
Property Address
Qr �
Owner Owner's Name / 1
information is 1-10 g 4#11 S /T
required for every _ cI
page. City/Town State Zip Code Date of Ins ection
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 C.4 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 o
❑ mping information was provided by the owner, occupant, or Board of Health
❑ ere any of the system components pumped out in the previous two weeks?
❑ s 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?
i 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?
I Was the site inspected for signs of break out?
Were all system components, excluding the SAS, located on site?
lo
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?
XE
he size and location of the Soil Absorption System (SAS) on the site has
een determined based on:
xisting information. For example; a plan at the Board of Health.
etermined 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)]
rev.'/2fir201 1 itle otazi inspe�nor=ern:SUDSCR2Ce sewage Disposal system.•?age 5 of?e
5insp.'oc• 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
er
Owner Owner's Name
information is
requi-ed for every ���
page. City7own State Zip Code Date of I/spec_tio/�__
D. System rnformation
.1. Residential Flow Conditions: 2
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 3
Description:
oyv
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
Does residence have a water treatment unit? ❑ Yes No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ❑ Yes No
Laundry system inspected? ❑ Yes No
Seasonai use? es ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes
G�r.•�
Last date of occupancy. date
R
6insp.doc•rev.1126%20�8 -the:o,ida.specdor=or-m.SUD5c2Ce sewage.Disposai System-Page 7 of 18
Commonwealth of Massachusetts
9 I� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Fer,; .4 so✓f
Owner's Name
information is (17
required for every �v) f
page. CitylTown �
State Zip Code Date of I specti n
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 occupancyiuse:
Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped:
g2liors
How was quantity pumped determined?
Reason for pumping: —
t5insp.doc•rev.728/20i8 `tie 5 Of,' al!rspect:cn Fom,:S,csc`ace Sewage Disposai System•?age a of 18
Commonwealth of Massachusetts
�w Title 5 Official inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Fe'r50So
Owner Owners Name / odb 0/ A-Z/62
0
information is 7
required for every
page. City/Town State Zip Code Date of In pection
D. System Information (cont.)
4. Type of S m:
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 l/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all coya Pon¢nts, date installed known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes o
5. Building Sewer(locate on site plan):
Depth below grade: feet
Material of constructio:�o
:
❑ cast iron" F.PVC ❑ other(explain): r
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
- s
'iJe 5 `cal i^spxticn r SuGa a Sewage Disposal System•?age 9 0f i
t5insp.doc•rev.7f2612018
Commonwealth of Massachusetts
z Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
✓. �s0
Owner Owner's Name
information is required for every A✓1✓1/s 0c)ov
0 1 6
page. City/Town State Zip Code Date of Ins ction
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade:
reet
Material s ruction:
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 certifica ) ❑ Yes ❑ No
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness �� G
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle -0
How were dimensions determined? kstructural
Comments (on pumping recommendations, inlet and outlet tee or barfle conditi , integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
(-24
t5insp.doc•rev.7/26/2018 Trie 5 JtScai Irspecticn Form.SuDsurace Sewage Disposes System.?age 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
,, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
"lar ('14
Property Address
Owner Owner's Name
information is A 0.)6v,
required for every A'4
page. City/Town State Zip Code Date of Inspecti i
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
r
Distance from top of scum to top or 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:
I
Capacity: gallons
Design Flow: gallons per day
.;-je 5 Ct`aal inspection Fom S:0o rfa sewage Disp�sai System•?age 1 i of 18
t5inso.doc•rev.',126i20l8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
3S3 4f� �1 Q
Property Address
Owner Owner's Name XV
information is od Q ) & a 0
required for every � h� - ` (� I
page. Cityrro`^m State Zip Code Date of Infection!
D. System information (cons.)
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 �Ve
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.): .
��o �e��S
t5insp.00c•rev.7262018 ?,7e 5 c21 knspaCuon Four.suns ,face sewage Disposal System•?age 12 of 18
Commonwealth of Massachusetts
s. ? Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
` ter ..�5.3 ,���ll c✓G
Property Address
Owner Owner's Name I
information ort is G N n
required for every
page. City(Town State Zip Code Date of I specti
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No`
Alarms in working order: ❑ Yes ❑ No'
1 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: ,
32
Type: ! \
• ❑ leaching pits number:
❑ leaching chambers number:
leaching galleries number:
❑ leaching trenches _ number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovativeiaitemative system
Typeiname of technology: ----- -----
-tie 5 7`aa:!nsperJon=0m:SucsLrta:a sewage Disposai system•Page 13 of 18
t5insp.410c•rev.7125/20 18
/
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Volun ry As essments
Property Address
Owner Owner's Name
information is ll``,
required for every of.4 rf! ��o Q �4-
page. City/Town State Zip Code Date of In ection
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.):
r .
�►r lane,i
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer-
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
ge D�sposai System•?age t4 of 78
tsm.p.doc•rev.726/2018 ',te 5 0fica!nspec'dol=om.sucsu=ace sewa
i
Commonwealth of Massachusetts
to Title- 5 Official Inspection Form
�, id" Subsurface Sewage Disposal System Form - Nqj for olun ry Assessments
S3 _ ,: f
Property Address W G
��• S v
Owner Owner's Name vt
information is Q�4
required for every
page. CityRown State Zip Code Date of Insp ction
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil: signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.4oc•rev.;/2620i8 Tice 5 O'❑a;nspeccon=orm.scosurace sewage Disposal system-Page 1.5 of 18
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntar
y Assessments
3 � d t,✓�
Property Address A
Owner Owner s Name 19 d
information is I��1 C7
required for every G' d l S � �J
page. City/Town State Zip Code Daie of I pectiort
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 b -chmarks. Locate all wells within 100 feet. Locate where public water supply enters
;dUravving
ildin heck one of the boxes below:
nd-sketch in the area below
attached separately
i
Itle
i .
I i
I
•
i
� I
I
t6insp.Coc-rev.712612018 - ?Ide 5 OfIcai Inspection=orm:sucscrface sewage Disposal System•Page 16 of 19
6/6/2020 Assessing As-Built Cards
FBARNSTABLE
LOCATION 3S3 ji[,��0 A SEWAGE q
VILLAGE )E4A 1iJ ASSESSOR'S MAP&LOT 2-9/- 0i.1-
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
ELEACHING FACILITY:(type) �Ii •L ,,PJV, fsize) 3b�X l/�X a
NO.OF BEDROOMS 3' _
BUILDER OR OWNER A/W.S �AQn
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of teat ng facility) J Feet
Furnished by T-4 gn T IG¢rC
r
A Q
-to
Tam�V
r Ya a3 v� 3
a ,Yl a-7 Holo
} t ,
'let �
3y L 30
https://townofbarnstable.us/Departments/Assessing/Property_Values/HMd isplay.asp?mappar=291012&seq=1 1/2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
141
Property Address
Owner Owners Name
information is
required for every AC17G 4 h 15
page. City/Town State Zip Code Date of In pectin
rl
D. System Information (cost.)
15. Site Exam:
L._I Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water:
dQ
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
served site (abutting property/observation hole within 150 feet of SAS)
Checked with ioc ' Board of Health - explain:
*
Eli
Checked with local excavators; installers - (attach documentation)
❑i Accessed USGS database- explain.-
You must describe no oouu�stablished the high
-ground water elevation:
0 9 4,t/a
`J 1
S� /-�• S t s c�o �c
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
tsinsp.doc•rev.'Fai2018 -'Iue 5 o iaai.nspeczcn Fern.suosurface Sewage Disposal System•page 17 of 18 .
Commonwealth of Massachusetts
Tiffp Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
141,
Property Address
Owner
Owners Name r
information is
required for every ✓�✓!�j / C�f00/ �o�' pt�
page. City/Town State Zip Code Date of I pectin
E. Reporf Completeness Checklist
Complete all applicable sections of this form inclusive of:
L✓f�B*:
pector Information: Complete all fields in this section.
ifcation: Signed & Dated and 1, 2, 3,.or4 checked
C. inspection Summary:
1, 2, 3, o completed as appropriate
4 ailure 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
f
t5insp.doc•rev.7Q612018 "7ue 5?`aa;mspecjor.=orr:.Suzsu'ac sewage oisposai system.?age 18 of 18
Commonwealth of Massachusetts' ,,,
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form,-' Not for Voluntary Assessments
°wM 353 MITCHELLS WAY C
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name +S7
information is required for every HYANNIS J MA 02601 10/30/2016
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 # �I�
filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not JOHN P GRACI SR
use the return
key. Name of Inspector
GRACI SEPTIC INSPECTIONS LLC
r� Company Name
PO BOX 2119
Company Address
TEATICKET MA 02536
City/Town State Zip Code
508-641-6694 S1468
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 Evalu on by the Local Approving Authority
ALI/
10/30/2016
Inspector's Signature Date
The system inspector sl I submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 0 days of completing this inspection. If the system is a shared system or
has a design flow of 10, 0 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate egional 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
4T#Vs
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
page. Cityrrown 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:
AT TIME OF INSPECTION ALL COMPONENTS APPEAR TO BE STRUCTUARLLY SOUND AND
FUNCTIONING PROPERLY.
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):
NA
t5ins-3/13 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
M 353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
page. Cityrrown 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):
NA
❑ 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):
NA
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
,M 353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
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: NA
**This system passes if the well water analysis, performed at a DER 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:
NA
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 '/z day flow
t5ins•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
M 353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
page. City/Town 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 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•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 353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
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?
® ❑ 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): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
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
wM 353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
1500 GALLON SEPTIC TANK DISTRIBUTION BOX (4) FOUR -HI CAP INFILTRATORS
MEASURING 30'X 11'X 2'
Number of current residents: (2) TWO
Does residence have a garbage grinder? ❑ Yes ® No
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 ears usage TOWN
9 ( Y 9 (9pd))�
Detail:
2015 2900 CUBIC FEET 2014 5800 CUBIC FEET
Sump pump? ❑ Yes ® No
Last date of occupancy: OCCUPIED
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: NA
Design flow(based on 310 CMR 15.203): NA
Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc.): NA
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: NA
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments
M 353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: NADate
Other(describe below):
NA
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: NA
gallons
How was quantity pumped determined? NA
Reason for pumping: NA
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
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
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:
UNKNOWN PERMIT DATE ON FILE IS NOT COMPLETED
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
26
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC 40 PVC
❑ other(explain):
Distance from private water supply well or suction line: 10+ FEET
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK APPEARS TO BE STRUCTURALLY SOUND AND FUNTIONING PROPERLY AT
TIME OF INSPECTION NO SIGNS OF HYDRAULIC FAILURE AT TIME OF INSPECTION.
Septic Tank(locate on site plan):
Depth below grade: (2)TWO FEET
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
SEPTIC TANK APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY AT
TIME OF INSPECTION. UNABLE TO INSPECT UNDER NORMAL USAGE.
If tank is metal, list age: NA
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 GALLON
Sludge depth:
(4) FOUR INCHES
t5ins-3/13 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
353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
page. City/Town 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 (30)THIRTY INCHES
Scum thickness ZERO
Distance from top of scum to top of outlet tee or baffle (6) SIX INCHES
Distance from bottom of scum to bottom of outlet tee or baffle ZERO
How were dimensions determined? MEASURED/VIEWED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
SEPTIC TANK APPEARS TO BE STRUCTURALLY SOUND AND FUNTIONING PROPERLY AT
TIME OF INSPECTION NO SIGNS OF HYDRAULIC FAILURE AT TIME OF INSPECTION
RECOMMEND PUMPING EVERY TWO YEARS.
Grease Trap (locate on site plan):
Depth below grade: NA
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
NA
Dimensions: NA
Scum thickness NA
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
Date of last pumping: NADate
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
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
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.):
NA
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: NA
Capacity: NA
gallons
Design Flow: NA
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: NA Alarm in working order: ❑ Yes ❑ No
Date of last pumping: NA
Date
Comments (condition of alarm and float switches, etc.):
NA
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 353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
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 BOTTOM OF PIPE
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.):
DISTRIBUTION BOX APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING
PROPERLY AT TIME OF INSPECTION.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
I�
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number: NA
® leaching chambers number: (4) FOURINFILTRATORS
❑ leaching galleries number:
NA
❑ leaching trenches number, length: NA
❑ leaching fields number, dimensions:
NA
❑ overflow cesspool number: NA
❑ innovative/alternative system
Type/name of technology: NA
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
(4) FOUR INFILTRATORS WERE VIDEO INSPECTED . INFILTRATORS WERE EMPTY AT TIME
OF INSPECTION. NO SIGNS OF HYDRAULIC FAILURE
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
Depth—top of liquid to inlet invert NA
Depth of solids layer NA
Depth of scum layer NA
Dimensions of cesspool NA
Materials of construction NA
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 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
353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
page. City/Town 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.):
NA
Privy(locate on site plan):
Materials of construction: NA
Dimensions NA
Depth of solids NA
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
NA
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
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
DEGk-
Aa 4-2
A-2-43� Ic
�3 AlLk
-
23 D2- I�2 1 o
21 2 0
F- 3D
d- I
C- 131 3
C3� M
t5ins.doc•rev.6116 Title 5 Officlel 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
353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
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
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:
HAND AUGER
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 353 MITCHELLS WAY
Property Address
RODRIGUEZ OMAR AND JENN
Owner Owner's Name
information is required for every HYANNIS MA 02601 10/30/2016
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
I
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
353 Mitchells Way
Property Address
Jeremy Richard '
Owner Owner's Name
information is required for Hyannis MA 02601 6-16-2010
every 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:. A. General Information
When filling out
forms on the
computer, use
only the tab key ` 1. Inspector: I
to move your Darrell Stone
cursor-do not Name of Inspector
use the return
key. Cape Cod Septic Inspection
Company Name
PO Box 1466 '
Company Address
Harwich MA 02645
�nnn CitylTown. State Zip Code
508-240-2500 S14995
Telephone Number License Number
B. Certification
I cert[fy that I have personally inspected the sewage disposal system at this address and that the
o., information reported below is true, accurate and complete as of the time of the inspection. The inspection
t .- was performed based on my training and experience in the proper function and maintenance of on'site
sewage disposal systems. 1 am a DEP approved system inspector pursuant to Section 15.340 of
6.:
s Title 5.(310 CMR 15.000).The system:
C cis
MP ses ❑ Conditionally Passes ❑ Fails
r . F ❑ e F rther Evalua ` n y t el- Approving Authority
6-18-2010
pec s Signatu Date
The system inspec or 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.
V U
11C
Title 5 official Inspection Form:Subsurface Sewage D ispo I System•J�t
of 17
t5ins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 353 Mitchells Way
Property Address
Jeremy Richard
Owner Owner's Name
information is required for Hyannis MA 02601 6-16-2010
every page. Cityrrown 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:
Septic tank was pumped after inspection
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-09l08 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 353 Mitchells Way
Property Address
Jeremy Richard
Owner Owner's Name
information is Hyannis MA 02601 6-16-2010
required for State Zip Code Date of Inspection
every page. City/Town
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):
r
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 3 of 17
t5ins•09/08
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 353 Mitchells Way
Property Address
Jeremy Richard
Owner Owner's Name
information is required for Hyannis MA 02601 6-16-2010
every 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 coliform
presence of ammonia nitrogen and nitrate nitrogen is equal to or
bacteria indicates absent and the g 9
p
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:
r
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
El
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 'h day flow
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
t5ins•09108
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
353 Mitchells Way
Property Address
Jeremy Richard
Owner Owner's Name
information is required for Hyannis MA 02601 6-16-2010
every 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:
❑ ® 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 publicwell.
❑ ® 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
❑ z 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
a ® 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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
t5ins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 353 Mitchells Way
Property Address
Jeremy Richard
Owner Owner's Name
information is required for Hyannis MA 02601 6-16-2010
every 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?
❑ 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
® ❑ maintenance of subsurface sewage disposal systems?
information on the propeti^ g p Y
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): N/A Number of bedrooms (actual):
2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
220
t5ins•09/08 Title 5 Official Inspection Form:Subsurface sewage Disposal system-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
353 Mitchells Way
Property Address
Jeremy Richard
Owner Owner's Name
information is
required for Hyannis MA 02601 6-16-2010
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
2 bedroom residential dwelling
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes Z No
Laundry system inspected? El Yes ® No
Seasonal use? ❑ Yes ® No
g ( y g (gpd)): '09 82,000
Water meter readings, if available last 2 ears usage '08 101,000 gal.
Detail:
t
Sump pump? ❑ Yes ® No
Last date of occupancy: 6-2010
Date
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
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
wM 353 Mitchells Way
Property Address
Jeremy Richard
Owner Owner's Name
information is required for Hyannis . MA 02601 6-16-2010
every page. City/Town State Zip Code Date of Inspection
D. System Information(cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Discount Septic Pumping
Source of information:
Was system pumped as part of the inspection? ® Yes ❑ No
1500
If yes, volume pumped: gallons
How was quantity pumped determined?
Weight
Maintenance
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):
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 8 of 17
t5ins-0908
Commonwealth of Massachusetts
o- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 353 Mitchells Way
Property Address
Jeremy Richard
Owner Owner's Name
information is required for Hyannis MA 02601 6-16-2010
every 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:
2000 per BoH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
19
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
I Distance from private water supply well or suction line: feet
I' Comments (on condition of joints, venting, evidence of leakage, etc.):
Apparent good condition
Septic Tank(locate on site plan):
14
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 of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1500 gallon
Dimensions:
12"
Sludge depth:
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 9 of 17
t5ins•09/08
Commonwealth of Massachusetts ,
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
353 Mitchells Way
Property Address
Jeremy Richard
Owner Owner's Name
information is Hyannis MA 02601 6-16-2010
required for y
every page. City/Town 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
20"
2 Scum thickness
5
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle 15
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.):
Normal liquid level No sign of leakage SCH 40 outlet tee
Septic tank was pumped after inspection
Recommended maintenance pumping-every 2 3 years
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
Title 5 Official Inspection Form:Subsurface sewage Disposal System•Page 10 of 17
t5ins•OW08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s 353 Mitchells Way
Property Address
Jeremy Richard
Owner Owner's Name
information is Hyannis MA 02601 6-16-2010
required for y
every 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:
Material of construction:
I
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): .
Dimensions:
Capacity: gallons
Design Flow: gallons per day
' Alarm present: ElYes ❑ 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
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 11 of 17
t5ins•09108
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 353 Mitchells Way
Property Address
Jeremy Richard
Owner Owner's Name
information is required for Hyannis MA 02601 6-16-2010
every 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 0
11
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.):
Grade to box 22" OK condition 1 Outlet Normal liquid level
No sign of leakage Heavy scum (removed) No sign of failure
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•09/09 Title 5 Official Inspection Forth: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
353 Mitchells Way
Property Address
Jeremy Richard
Owner Owners Name
information is Hyannis MA 02601 6-16-2010
required for y
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4
❑ 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.):
4 Infiltrators with 4' stone
Grade to infiltrator 29" Observation port 8" Bottom 44" Trace of water
No sign of hydraulic failure
4
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
Title 5 Official Inspection Forth:Subsurface Sewage Disposal system•Page 13 of 17
t5ins•09/08
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
353 Mitchells Way
Property Address
Jeremy Richard
Owner Owner's Name
information is
required for Hyannis MA 02601 6-16-2010
every page. City/Town 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•09/03 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
353 Mitchells Way
Property Address
Jeremy Richard
Owner Owner's Name
information is Hyannis MA 02601 6-16-2010
required for
every 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
Fro _
LA
Shed
d O
2
a
� 3
A B
2 4,54 26-s
3 lcl-0
4
5
6
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
t5ins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form t
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 353 Mitchells Way
Property Address
Jeremy Richard
Owner Owner's Name
information is Hyannis MA 02601 6-16-2010
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
® Check cellar
Shallow wells 1
>5
Estimated depth to high ground water: 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 propertylobservation hole within 150 feet of SAS)
Checked with local Board of Health -explain:
Certificate of Compliance on file
❑ Checked-with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
See Below
You must describe how you established the high ground water elevation:
Elevations from USGS maps
Approx. Property ELV. 46.0
Approx. Bottom of SAS ELV. 42.34
Approx GW ELV. 20.0
Separation >5'
Before filing this Inspection Report, please see Report Completeness Checklist on next page. .
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
t5ins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM ,. 353 Mitchells Way
Property Address
Jeremy Richard
Owner Owners Name
information is Hyannis MA 02601 6-16-2010
required for y ,
every 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
t5ins-09/03 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17
E,G
TOWN OFBARNSTABLE
,gyp
LOCATION �� .> I A O tam!4� SEWAGE #
VELLAGE a'1 - ASSESSOR'S MAP & LO
I TOV
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK-CAPACITY 1 SOS A3�
)LEACHING FACILITY: (ty ) a-&c k C5 , (size)
, NO.OF BEDROOMS 3
BUILDER OR OWNER 7T w
PERMIT DATE: OMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility)facili Feet
Furnished by
i
� -
�/ ____ _ , 1.
c� � , �
� �' � -.
� � � �"
,r � �.
� � �� � � �
a
,-
-�_
� - goo
� � � �
Q � � �
� � � �
6 �-, i G' r.� c1�p ,
. � � a o.J � _., r-
F � � �, � �
c IN �": �,�
--
No.'1./5 � Fee c
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppYication for Migpogaf 6pgtem Congtruction Permit
•y Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ;Complete System ❑Individual Components
Location Address or Lot No. 7K5 t Owner's Name,4Address and Tel.No.
Assessor's Map/Parcel ag
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
1V-PA-(-W-S-eqO 1L.
� S lvvls 5T<
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures 7
Design Flow -J0 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 14S O'D I Type of S.A.S. t �T
Description of Soil COt2 S14
N tur of Repairs or Alteratjons(Answer when applicable) Ste ``,
1 l� r C�c l� �i uJ C l _ fit.51 Oe
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has een issued by this o
Signed Date
Application Approved by Date 45"—Ad
Application Disapproved forte folio ing reasons
Permit No. Date Issued
TOWN OF BARNSTABLE 011 -
LOCATION 3 1I1 SEWAGE # 7�J
1 ,, �, t
VILLAGE 1�-ll j� v,_A.v S ' _
ASSESSOR'S MAP & LOT O
INSTALLERS NAME&PHONE NO. � O—C>��-s�
i
SEPTIC TANK CAPACITY .
LEACHING FACILITY:
(ty,
NO.OF BEDROOMS 3
AU
BUILDER OR OWNER ,vU .. ...
PERMDATE: C�0 COMPLIANCE DATE: d Q
Separation Distance-Between the:
l Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist :
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and.Leaching Facility(if any wetlands exist
within 300_feet of.leaching facility) Feet
Furnished'by.
�.01\1
\ J
w
No. /S�ivs �l 4 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
` Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ZIpprication for -Migogar *p.5tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) XcompleteSystern D Individual Components
Location Address or Lot No. -:E 3 1 C `� _Ip- Owner's Name,Address and Tel.No.
r----
Assessor's Map/Parcel aq� 'RG use
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Y0 I r) LIA(,k_2 Sr(,TI L
15 loviC_
Type of Building:
Dwelling No.of Bedrooms Lot Size L sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �� gallons per day. Calculated daily flow ��-�� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank I'S efV S,1 Type of S.A.S. C'4focC`r`t
Description of Soil Co'4t2� 14 S ,� T�—P
atur of Repairs orAltera 'ons(Answer whenapplicable)
ct a�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has issued by�this B ` h.
Signed Date ZlEz2)/
Application Approved by Date ( t1�
Application Disapproved for Re follVving reasons
Permit No. ' !4 l =2t Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
f
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded
Abandoned( )by
at 3J 3 YK-V- ti has been constructed in accordance
with the provisions of Title 5 and the for Disposal System donstructAn Permit No. dated
Installer Designer / n
The issuance o is 'eVnit shall not be construed as a guarantee that the s 9te-ni will functi n as�deJhigned; ,/�✓r' Q ��
Date Inspectors l// .f /� ���-_ ✓
----------------------
No. V. 3 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Disposal *pstem Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgra e bandon( )
System located at JC
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: Approved by 5151
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, 70 e L�' , hereby certify that the application for disposal works
construction permit signed by me dated [j , concerning the
property located at ��� /f Ib~>� ri� s meets all of the
following criteria:
• This failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
Mere are no wetlands within 100 feet of the proposed septic system
• 'here are no private wells within 150 feet of the proposed septic system
• T re is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
/
v• The bottom of the proposed leaching facility will not be located less than five feet above the maximum
adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when
cable]
• If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
,groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W.Elevation ��-►!l/+the MAX.High G.W.Adjustment4�(7
DIFFERENCE BETWEEN A n ��
SIGNED : Cam/ DATE:
[Please Sketch pro d plan of s m on back].
NOTICE
Based upon the above information,a repair permit will be issued for bedrooms maximum. No
additional bedrooms are authorized in the future without engineered septic system plans.
q:health folder:cert
ti
e'
�)
� �� � .