HomeMy WebLinkAbout0385 MITCHELL'S WAY - Health 385 Mitchells Way, Hyannis
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TOWN O1F�B,ARNSTABLE
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LOCATION�� ►`AkYW, SEWAGE# ,.IUoi� `p1 IS
VILLAGE qAW_h15 ASSESSOR'S MAP&PARCEL �
INSTALLER'S NAME&PHONE NO'-JM M &C,COSD ,-PA
SEPTIC TANK CAPACITY S CXl
LEACHING FACILITY: (type) (size) x`�,
NO.OF BEDROOMS
OWNER \ Z%\)�
PERMIT DATE:�A V la 1 COMPLIANCE DATE:77/8/a i
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 exi within
300 feet of leaching facility) �� Feet
FURNISHED B 10_"
00
95
0
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TOWN OIF:.BA.RNSTABLE
LOCA IbN J�J�'` c4e115 fN r'11/ SEWAGE # _
VII:LAGE ASSESSOR'S MAP& LOT
'I JNSTA: ER'S NAME&PHONE NO.
SEPTIC TANK-CAPAcm COJC � S
i LEACHINNG FACILITY: (tyke) "4` (size) lt�D
!
Nd.OF BEDROOMS
BUILDER CAR OWNER ,..
{_FE ITDATII:. _........_._._..d..: _COIvWLIANCE DAT,:— -
Separation Distance Between tbe:
Maximum Ad}ustit,Groundwater Table to the Bottom of Leaching Facility Eee
Private Water Supply Well and Leaching Facility (If any wells exist
V on site or within 200 feet of leaching facility)
Edge of Wedand and Leaching Facility(if any wetlands exist
within 300 feet o leaching facility) >i ecs
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Furitlshed by — ,�ro _....
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41 `
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TOWN OF BARNSTABLE
LG '=.TION. SEWAGE # '
VILLAGE Jk(,,)K\ ASSESSOR'S MAP & LOT �-
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INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 0t�1 LL"
Cax�car. �1T
LEACHING FACILFTY:'(type) 15J -(size) \ N1.x S2
NO.OF BEDROOMS
BUILDER OR OWNER a C—
PERMTTDATE: l COMPLIANCE DATE:
Separation Distance Between the;
Maximum Adjusted Groundwater Table �' Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wedand and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by (��.(�
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-------------------------------------------------------- -------------------- ---------------------------- ---- -------------------------------------------------- ----------------------------------------------- - ------------------------ ---------
. No. TWECOMIMONWEALTH OF MASSACHUSETTS FEE dy
BOARD OF HEALTH
— OF
APPLICATION FOR DISPOSAL SYSTEM ONSTRUCTION PERMIT
Application for a Permit to Construct Repair Upgrade (%4 Abandon System C]❑Individual Components
ZAS M�—k UltLC-5 WM RUST
r\3 M WARM ft) LL R�
Affires.
LANTEky I?
M KE_ SWIMNP/
ic,
77q -,,? Ci�eejq 14r, _1 V 10M.I`1�1
I Telephone If Telephone
Type of Building: f)W C>1 U M� _/9 Al Lot Size 41=L-Ap-
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers Cafeteria
Other fixtures
Design Flow(min.required) 3 S 0 gpd Calculated design flow-341 gpd Design flow provided 3qj gpd
Plan: Date Number of sheets Revision Date
Title--- SEWT=- STC-SILIA OfSTER
L I
Description of Soil(s) L) L. S 18 �I-L 5 1 i-I n M - F. S ARA I C 3
Soil Evaluator Form No Name of Soil Evaluator a of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS UP G*Rid DLL,_5dQ 5-,ST' S'n'X?!
J,
P VL,I—C l vt 11 h Zk' D ZU BLE 'N-7SrV ft I IS 15 7 1 Ul\1 j 0 (3 1 U RE J I L
The mqo _jns• qb-o:yq Oes;044!!tOM4
ogress Disposal System in accordance with th�m provisions of
TffU 5 and, the system! operation
nU0la.Qr"wieofC*m is/sued Ili the&Mid Of H"Ith.*
pliancehasbeen ued
Signed Date
InVections
FORM 1 - APP.L.I.CAT,19N FOR Dr:?CP DEP APPROVED FORM 5/96
_ -------
C
¢.
10
r
No _L2
lJ THE COMMONWEALTH OIL 'M`ASSACHUSETTS. FEE
BOA-1 ' D OF HEALTH
TflW l�' OF-
APPLICATIONBRST> BLL
% FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
co
s A lieation for a Permit to Conn ,PP t rucl ( ) Repair ( ) ll� r.ld� Abandon 1
� P _I!- (YI ( ) - C'om ie�ystem (]Individual Components
RVST
Map/Parcel r
HARP�Jdro_ \
M 1 E SWEI�VL- / L -
/
als
Telephone It Telephone N
Type of Building: ._ r�11'� Lot Size o •
Dwelling—No.of Bedrooms Garbage Grinder ( )
Other—Type of Building No.of persons Showers ( ), Cafeteria ( )
Other fixtures
'Design Flow'(min required) 33 Q gpd .Calculated design flow 3�' gpd Design flow provided33 gpd
Plan ,Date Nu b r o A ets Revision Date
g ,T'itle 'k _ 5 46 1�1 `.�,r`5C1
t
Description pf Soil(s) 8�+ L,S` 'l--5�. '� 3`� '." 5 A�
Soil Evaluator Form,No. Name of Soil;:Bvaluafor
DESC ION OF R RS lyt E S U � ������ � e.,ofsEvaluat on
)J Ic . �jj O ,8B8 its` r �a c�1 T �►�rx�'
ARU1
L
x The undersr dd agrees to rnatoll ."above'deseribed Fndrviducl Sewage Disposal System in geeondance wink the provisions of
f-TITLE 5 and revs not ro `lac�the s stem in ,a9 p y operation until o 0"'Ti�c, of Compliance has bow issued by the Board of i)t mhh.
Signed P % rv'Date
Ins it'ctions
0ORM-1 APPLICATION FOR DSCP DEP APPROVED FORM 5/96 ,-
— — .----
? --—
NO. THE COMMONWEALTH OF MASSACHUSETTS` FEE
13 l�Rl�lS
L•B OARD OF HEALT
3
- _ T�1� H. :.
r' CERTIFICATE OF COMPLIANCE {
Description of Work: ❑ Individual Component(s) Pircomplete System
The undersigned'hereby certify that the Sewage Disposal System,Constructed( ),Repaired( ),Upgraded(Y�.Abandoned( )
by: E NR L L A)N _T L T_`/ P
at 3$� 1�IT-Cl1 L• LLBS WA-1
has been installed to accord an a with-the p visions of 311 t> % 0( Tit 5) an t e approved design lams/as-built
plans relating to application No.1W i dated / + iipt d Design 1�1g (gpd)
Installer m'L hOA U ( 7
`S �e� vG��� Corp,
'CARL LAIN T L P `1 PL ' y
Designer: Inspector Yi'!!6s,,. r ; );}l- ,G: Al '•' Date
The issuance of this certificate shall not be construed as a'guarantee that the system,�will function as designed.
FORM 3 - CERTIFICATE OF COMPLIANCE DEP AP:PROV-ED FORM 5196
--------------
/// ..
No. THE'COMMON.WEALTH OF MASSACHIUSETTS ' FEE ZAP, Q� $LL BOARD "OF HEALTH y
DISPOSAL SYSTEM?CONSTRUCTION PERMIT'
Permission is hereby a dA�p C.p r t (� ) step ( ) Upgrade ( !') Abandon ( ) an-individual sewage
disposal system at !�\ ( ` M S as described
in the application for Dis osal-S.-stem-Constructi - - da °�
p y on Per-mit No.__�_ .dated l
Provided:. Construey ion sppall be completed within three years of the date of this per 't.All ®cal Condit" ns must be met.
�/�Y11 (
.Date Board of Health dln/
FORM 2- DSCP DEP APPROVED FORM 5/96
FORM 1255 (REV 5/96) H&W HOBBS&WnnFE TM PUBLISHERS-BOSTON
/ t
H. EARL LANTERY, PE
Consulting Civil / Environmental Engineers
18 RT 6-A, SANDWICH, MA 02563
r
1-774-313-9547
Barnstable Health Department
200 Main Street
Hyannis, MA 02601
Subject; Depth of drainable soils at 385.1VIetchell's Way
dear Sir/Ms;
I have observed that there is five feet of of well drained soils (sands and
grave) below the,bottom of the installed S.A.S.
Attached is the stamped copy of the Certification_Form.
If you have any questions, call me @ 774-313-9547.
Ea Lantery PE
O�
y N,
LANT Y,
A .p No. 515
Fss�ONAI ECG\ c
i
Town of Barnstable
Inspectional Services
Public Health Division
Hnntvsraats,
't"ss Thomas McKean,Director
�o Sys 200 Main Street,Hyannis,MA 02601
`Office: 508-862-4644 k Fax: 508-790-6304
Installer& Designer Certification Form
Date: -� - ` Z� Sewage Permit# v (� Assessor'ssMap\Parcel
Designer: L,Installer: 1 ")(+, 1 �I 1 4 (w—A
Address: 1 i� R-—MA S KNOW Ch'1 Address:
On I was issued a permit to install a
(date) (i staller)
septic system at 5 �`� 1T C 1 1�1 5 \ j based on a design drawn by,
(address) .
dated
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (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
certified as-built by designer to follow. Strip out (if required) was inspected and the soils
were found satisfactory.
,I ertify that the system referenced above was constructed in compliance with the terms of
he I1A approv l letters (if applicable)
SN OF
(Instal er s Sig ure HARRY
c EARL
r T c TERY, 1R.
(I Y e S i gh er Signa '.re)......_- ...� ( sQ E� Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALT ISION. 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.
\\toa\deptslHEALTMSEWER connect\SEPTic\Designer Certification Form Rev&14-13.DOC
Commonwealth of Massachusetts
Title 5 Official..lnspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
385 Mitchells Way
Property Address
Bank Owned (Contact David Holt,@ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-23-11
-
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.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Service
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
CityfTown State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification -
-
certify that I.have personally inspected the sewage disposal system at this address and thanhe
information reported below is true, accurate and complete as of the time of the inspection. Teel inspection
was performed based on my training and experience in the proper function and maintenance of on side
sewage disposal systems. I am a DEP approved system inspector pursuant to 4ection 140 cva
Title 5(310 CM 1.5.000).The system: W
.
E Passes ❑ Conditionally Passes ❑ Falls w
❑ Needs Further Evaluation by the Local Approving Authority
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.
�v I
V
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewag isposal System•P ge 1 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 385 Mitchells Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-23-11
page. City/Town 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
® 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 is in good working order with no sign of failure.
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-11110 Title 5 Official Inspection Form:Subsurface Sewage Dispose l System•Page 2 of 17
Commonwealth of Massachusetts ..,
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 385 Mitchells Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Hyannis MA 02601 5-23-11
required for every -� -
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water,level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain.below):
❑ obstruction is removed '° ❑ Y ❑ N ❑ ND (Explain below):
❑ ` distribution box`is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
. .system will pass inspection if(with approval of the Board of Health):
El broken pipe(s) are replaced ElY .❑ N• ❑ ND (Explain below):
t
❑ 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 CM
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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments
385 Mitchells Way
'M
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-23-11
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/day flow
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 385 Mitchells Way
Property Address
Bank Owned (Contact David Holt @ Today.Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-23-11
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:
f.
El ® 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 pI.rivy 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.
3
❑• ® Any porlion'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 9P
000 'd;
❑ ® 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 ina nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 385 Mitchells Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-23-11
-
page. CitylTown 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,
® ❑ p pe d, 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 (f any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330
t5ins-11/10 Title 5 Official Inspection 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 385 Mitchells Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Hyannis MA 02601 5-23-11
required for every H y "
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): ;
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 3-2011
t. i 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•1 MO TRIe 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
^M 385 Mitchells Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-23-11
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:
Source of information:
Was system pumped as part of the inspection? ® Yes ❑ No
If yes,volume pumped: �CSU J
gallonnss
How was quantity pumped determined? ►`�c` r
Reason for pumping: Required for inspection
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system ('ties or no) (f 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•11/10 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
385 Mitchells Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-23-11
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components,date installed (f known) and source of information:
1980's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below 30"grade: feet
Material of construction:
❑ cast iron ® 40 PVC ,° ' ❑ other (explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Good condition:
Septic Tank(locate on site plan):
3,.
Depth below grade: r'• 1 feet
Material of construction: Y a (A
® 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: 6'x6' block cessp000l
Sludge depth: 12
t5ins•11/10 Title 6 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
M 385 Mitchells Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-23-11
page. CityTTown State Zip Code Date of Inspection
D. System Information (cons.)
Septic Tank (cont.)
Distance from top of sludge to bottcm of outlet tee or baffle
36"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle 16"
Distance from bottom of scum to bottom of outlet tee or baffle 2
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Cesspool acting as main tank in good condition with baffles installed and not full at inspection.
Grease Trap (locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins-11/10 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
385 Mitchelis Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name -
information y
ation is Hyannis MA 02601 5-23-11
required for 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:
❑ 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
,z
Comments (condition of alarm.and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Tdie 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 385 Mitchells Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-23-11
page. City/Town State Zip Code Date of Inspection
D. System Information (cone.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, et--.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11/10 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
385 Mitchells Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-23-11
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-1000 gal
leaching chambers i number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments.(note condition of soil,.signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
Leach pit in good condition and empty at inspection with stain line at 30" below inlet invert.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins--11/10 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�qM 385 Mitchells Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-23-11
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•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal:system•Page 14 of 17
. e A
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 385 Mitchells Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-23-11
page. Citylrown 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
L?- J i
t5ins•11/10 - ,,, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 385 Mitchells Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-23-11
-
page. Cityfrown 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: 12
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you estaUished the high ground water elevation:
USGS and town maps show groundwater at greater than 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
�M 385 Mitchells Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-23-11
page. CitylTown 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
s
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 - Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
T
t
CO\I\10N,\1"".�i TH OF NL�SSAC 4USETT
EKECUTIVE OFFICE OF E\VIRON�IENT.�
DEPARTMENT OF ENVIRONMENTAL PROTECTION
>�. ONE R'INTER,
B'_)S70N NL4 0210S (61 2u2 .
TRUDY C )X=
Secre:an
ARGEO PALL CE .:: CC 8 VID B STR"HiS
Governor Co rsriss:_r.e:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR
PART A
CERTIFICATION
Property Address: 3�S �\C��\��j `^�� Name of Owner p3
�NNIS Address of Owner: Q\ F
Date of Inspection: � yh �V\> 1
Name of Inspector:IPleas��l� 1)
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.
Company Name: 1q7 rt 1#C r in+u.
oZ/�G/Marring Address:.? 0aey M/4sN
Telephone Number: 4 So-2! )—ICE 7 o
CERTIRCATION STATEJNE]VT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature_ Date: I
The System Inspector shall submit a copy of this Inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
i.
revised 9/2/98 page Iorn
i� Printed on Recycled Paper
( i
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
f_ I CERTIFICATION (continued)
'roperty Address: S�S
Jwnef:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. (SYSTEM PASSES:
/� I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
�T criteria not evaluated are indicated below.
COMMENTS: '
B. SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection; or
the septic tank, whether or not metal,is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board cf Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 page 2orii
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
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 ystem is failing to protect the
public health, safety and the environment.
11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 MR 15.303 (1)(b) THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SA F AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt m sh.
s
f
r'
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 AND AFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption system(SAS) nd 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 soil absorption system and he SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption system an the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system a d the SAS is less than 100 feet but 50 feet a more from a
private water supply well,unless a well water an for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the pre nce of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (contnued)
Property Address:
Owner:
Date of Inspecti
D. SYSTEM FAIL
You must indicate eit er "Yes" or "No" to each of the following:
I have deter ned that one or more of the following failure conditions exist as described it 310 CMR 15.303. The basis for this
determination identified below. The Board of Health should be contacted to determine ovhat will be necessary to correct the failure.
Yes No
Backup o sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge o ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid lev in the distribution box above outlet invert due to an overloadec or clogged SAS or cesspool.
Liquid depth in ces pool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping mo than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pump d
Any portion of the Soil Ab orption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or ivy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or priv is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is les -than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the ell has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compoun , ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes- or "No" to each of the following:
The following criteria apply to large systems in addition to the riteria above:
The system serves a facility with a design flow of 10,000 gpd or reater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the Ilowing conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking wat r supply
the system is located in a nitrogen sensitive area(Interim Wellhead Prot tion Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 C 15.304(2). Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION,FORM
PART B
CHECKLIST
property Address:
Owner:
Date of Inspection:
Check.if the following have been done: You must indicate either "Yes- or "No- as to each of the following:
Yes No
No Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and-the system has been receiving"ormal flow
rates during that period. Large volumes of water have not been introduced into the systerr: recently or as part of this
inspection.
X As built plans have been obtained and examined. Note if they are not available with N,A.
"C The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
x _ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees; material of construction, dimensions,depth of liquid, depth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example, Plan at B.O.H.
_ Determined in the field (if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
115.302(3)(b))
The facility owner(and occupants,if different from owner)were provided with information on the propermaintenanca-of
SubSurface Disposal Systems.
revised 9/2/98 Page of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION
'roperty Address-
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 g.p.d./bedroom.
Number of bedrooms (design):_6Z- Number of bedrooms (actual): b?j
Total DESIGN flow_
Number of current residents: ('
Garbage grinder (yes or no):
Laundry(separate system) ( es or®o A If yes, separate inspection required
Laundry system inspected a or no)
Seasonal use (yes or no): S
Water meter readings, if avaFable (last two year's usage (gpd):
Sump Pump (yes or no):_t�?
Lest date of occupancy: ,UmM-t-0-us Ay,
COMMERCIALANDUSTRIAL:
Type of establishment:
Design flow: gpd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)--N)
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool j6U/.►;F1oW ULacln
Overflow cesspool
Privy
Shared system(yes or no) (if yes, attach previous inspection records,if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information: -
Sewage odors detected when arriving at the site: (yes or no)_
revised 9/2/98 Page6of 11
c
-ti
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction: _cast iron _40 PVC_ other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:
(locate
(locate on site plan)
Depth below grade:_
Material of construction: _concrete _metal_Fiberglass _Polyethylene_otherlexplai
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_ (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 dimensions were determined:
'omments:
(recommendation for pumping, condition of inlet and outlet tees or baffle , depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
GREASE TRAP:
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass _,Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or ba
Distance from bottom of scum to bottom of outlet t e-or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of In t and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
revised 9/2/9 Page7or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Addres
Owner:
Date of Inspection:
TIGHT OR HOLDIN\TA : (Tank must be pumped prior to, or at time of, inspection)
(locate on site planDepth below gradeMaterial of construete _metal _Fiberglass_Polyethylene other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working der: Yes _ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and at switches, etc.)
DISTRIBUTION BOX:_ 7
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of tappurtenances,
e into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or Not
Comments:
(note condition of pump chamber,-condition of pu
revised 9/2/98 page s.oftt
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address: 3�S IIUI 1 l CJ��x
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible; exca tion not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:A �
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs ohydraulic failure, level of pon ing, da soil, c diti of vegetationetc.)
CESSPOOLS:�f�
(locate on site p an
Number and configuration: 1 \ U
Depth-top of liquid to inlet invert:
r)epth of solids layer: to '
)epth of scum layer: 8 q
Dimensions of cesspool: SNA X S
Materials of construction: CA&aC-*t—V-C ✓3-oc.
Indication of groundwater: (J
Inflow(cesspool must be pumped as part of inspection) 1
Comments:
(note condition of soil, signs of hyd, Wlic failure,level of ponding, condition of at n, etc.l _ v
t Z �0
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.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address: 2,vs t4a k\1s
)wnef:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference IandmarKs or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
CaLe���
a �
A1 - 36 �
AZ,- Lis �iZ� 3Z
revised 9/2/98 Page 10of11
r-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (contirwed)
;operty Address: 8S �v1tTcln>z��S
owner:
Date of Inspection:
NRCS Report name p—V --- — --- --
Soil Type -- --- ----- - - ---
Typical depth to groundwater ___ __ ____—_-_
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water jQ0
Check Cellar Him
Shallow wells r-bcc i
Estimated Depth to Groundwater t IJFeet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
--\Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page 11of11
i h
i TOT,C
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o
� � •. MATE A RC v 1�i A
�S�. 5 �N. fl .
I xrSTI mII Girl.�.It_ u. _ _
SyST�tw raI;�- FILTER
Q
--- A.c� S S
guru+»- Co.►�, , LEVEL M14.13'MAX covS?,
1 j-1 o-TEST - FRI I-TC 2 � I
F�LE�r�\ . - 1TC� �� t
91 --.- ... -<-
iN
L^ 1 } 5 �T1 C ?AA-`K �N o L.� � �: '.. �I�"IQ� `
4�-- ^r2uA�sragE off?ccxAPAC'i ca �_ 3f9•"?aS Ya D �-t
De-rrk ov- ��vjp •4 f ` MZia- 1 OT IN • -- �_..:�G U-A
J Al LET -ram 1)E?r R - I p'' O f3 L• Lor,J !
LL
NOTES:
i
1. Disposal System to be constructed in strict accordance with
PROF ® D I 0SAL `�``�� STD - �1vJ zf Commonwealth of Mass. Environmental Code —Title V. ,
2. This plan is for the sole purpose of construction of a septic system.
3. Contractor to call Dig-Safe 72 hours prior to beginning of excavation.
Gr
4. Pump existing pit, fill with sand and abandoned.
�T
�,�� Ike. 5. Use a new (H-10) 1,500 gal. septic tank. Install Tees and gas baffle.t �rJ�1( .
0 6. Contractor to field check invert of outlet at foundation. .
Z 7. Bench mark is to of foundation l .� p e ev 101.0.
8. APN is 291 / 014 for the Town of Barnstable.
,��.. op
rj 9. Locus is served by Town water.
rri
Y f 3
2� ' '`-- 10. The plan view is based on site Ian b John Witne RLS and
'tL7 p Y y,
t �3,, +- D� �D i recorded at Barnstable Reg. of Deeds plan bk 137 / 131.
11. Use 2-5'x8'x2' P.C.L.C. with 4' of double washed % " to 1 %" stone all
4 3 a around and filter fabric on top. Use an H-20 Disturbtion Box.
�� .— �c
12. Grade, loam and seed all disturbed areas.
r
L b
f Pu rf$
1 i TE Tr I
roll-
9°1.3 — LdRM iDY4J 4 r HARR cG
I gq_3 R N
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