HomeMy WebLinkAbout0128 OAKVIEW TERRACE - Health 128 Oakview Terrace
Hyannis
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Commonwealth of Massachusetts
al Title 5 Official Inspection Form
it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
128 Oakview Ter
Property Address
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Donna Mathes
Owner Owner's Name
information is }
= .,
required for every Hyannis MA 02601 10-25-16
page. City/Town State Zip Code Date of Inspection
. (V
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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 SI# /1983
1. Inspector:
r
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73 ,
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
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 16.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails,
❑;ji
r Evalu by the Local Approving Authority
10-25-16
I spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth'&Massachusetts
:arl fz Title 5 Official Ins
pect t ion Form
L•+ p
=+ hI Subsurface Sewage Disposal Sy
stem Form Not for Volnta .Assessments
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�.r a'
128 Oakview Ter
Property Address
Donna Mathes
`Owner Owner's Name
information is H required for every annis MA 02601 10-25-16
y
,page. City/Town State Zip Code Date of Inspection
CA
B. Certification (cont.)
Inspection Summary: Check AOC,D or E/always complete all of Section D
A) System Passes:'.
® 1 have not,found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
,,-W-I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� s I
128 Oakview Ter
L J'
Property Address
Donna Mathes
Owner Owner's Name
information is required for every Hyannis MA 02601 10-25-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ 'obstruction is removed t ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced [IY ElN ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to.broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C), Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
�,^I r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�_,,!✓ 128 Oakview Ter
Property Address
Donna Mathes
Owner Owner's Name
information is required for every Hyannis MA 02601 10-25-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
" 2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment: � , . .
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of'a surface water supply or tributary to a surface water supply.
❑ 'The system has a septic tank and SAS and the SAS is within'a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than,100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑, ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or pondin of effluent to the surface of the round or surface waters
❑ ® 9 9
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 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Dispo%W System-Page 4 of 17
Commonwealth of Massachusetts
a=1 Title 5 Official Inspection Form
rq (,
i-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
128 Oakview Ter
Property Address
Donna Mathes
Owner Owner's Name
information is required for every Hyannis MA 02601 10-25-16.
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
F 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
r
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection Fora
� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�F
128 Oakview Ter
Property Address
Donna Mathes
Owner Owner's Name
information is
required for every Hyannis MA 02601 10-25-16
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 I /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:
. 2 2
Number of bedrooms (design): Number of bedrooms (actual):
• DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
r f Title 5 Official Inspection Form
�A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments =.
128 Oakview Ter
'L J"
Property Address
Donna Mathes
Owner Owner's Name
information is required for every Hyannis MA 02601 10-25-16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
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 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 10-2016Date
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
• Commonwealth of Massachusetts
:a
f;6 Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
as;
128 Oakview Ter
Property Address
Donna Mathes
Owner Owner's Name
information is required for every Hyannis MA 02601 10-25-16
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: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: - gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no)'(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
NSubsurface Sewage Disposal System Form -Not for Voluntary Assessments
128 Oakview Ter
Property Address
Donna Mathes
Owner Owner's Name
information is H annis MA 02601 10-25-16
required for every y _
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:
1979
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"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):
Depth below grade: 18"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
Dimensions: 1000 gal
Sludge depth:
12"
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
• Commonwealth of Massachusetts _
^+ Title 5 Official Inspection Form
�7 Subsurface Sewage Disposal System Form -Not for VoluntaryAssessments
l.' 9 p Y
a�
128 Oakview Ter
Property Address
Donna Mathes
Owner Owner's Name
information is required for every Hyannis MA 02601 10-25-16
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"
1„
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
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.):
Tank is in good condition with baffles installed and no sign of leakage.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
I
Commonwealth of Massachusetts
al Title 5 Official Inspection' Form
'�-1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,_�_;;!✓ 128 Oakview Ter
Property Address
Donna Mathes
Owner Owner's Name
information is required for every Hyannis MA 02601 10-25-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
:a= Title 5 Official Inspection Form
' �� Subsurface Sewage Disposal System Form Not for Voluntary Assessments
128 Oakview Ter
Property Address
Donna Mathes
Owner Owner's Name
information is required for every Hyannis MA 02601 10-25-16
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
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.):
Good condition with water at working level and no sign of back-up from pit.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
V Commonwealth of Massachusetts
a=1 Title 5 Official Inspection Form
��I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
128 Clakview Ter
Property Address
Donna Mathes _
Owner Owner's Name
information is required for every Hyannis MA 02601 10-25-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit in good condition with water level and stain line at 24" off bottom of pit.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
I,^ Title 5 Official Inspection Form
011 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
s;,.,.
�
128 Oakview Ter
Property Address
Donna Mathes
Owner Owner's Name
information is required for every Hyannis MA 02601 10-25-16
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
° Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection Form
��I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
128 Oakview Ter
Property Address
Donna Mathes
Owner Owner's Name
information is required for every Hyannis MA 02601 10-25-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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4),3 1. o02 7 '
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t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
• Commonwealth of Massachusetts
I,^ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
128 Oakview Ter
Property Address
Donna Mathes
Owner Owner's Name
information is required for every Hyannis MA 02601 10-25-16
page. City/Town 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: 20
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:
USGS and town maps show groundwater at 20'.
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
Title 5 Official Inspection Form
W1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
128 Oakview Ter
Property Address
Donna Mathes
Owner Owner's Name
information is required for every Hyannis MA 02601 10-25-16
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of Massachusetts
1-41
W Title 5 Official Inspection Form
Subsurface Sewage.Disposal System Form - Not for Voluntary Assessments
„ 128 Clakview Terrace
Property Address,
Joseph and Heghineh Yavanian
Owner Owner's Name
information i e Hyannis MA 02601 January 31 2013
required for every ry
page. CitylTown 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 A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your p
cursor-do not David D: Coughanowr, R.S
use the return key. Name of Inspector.Eco-Tech Environmental
reb Company Name .
43 Triangle Circle
Company Address
Sandwich MA 02563
Cityrrown State Zip Code
u- 508 364-0894 1328
u Terephone Number License Number
c.e --
M Certification
ccl I certlfO—hat l 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
ram-, .was performed based on my training and experience in the proper function and maintenance of on site
N sewage disposal systems l am.a DEP approved system inspector pursuant to Section.15.340 of .
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes El rails
❑ Needs Further Evaluation by the:Local Approving Authority
Janua..31 2013
ry
Inspector's Signature Date'
The system inspector shall submit a- y p 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 10,00.0 gpd•or greater, the inspector,and the system owner shall submit the
report to the appropriate.,regional office.of the DEP. The original should be sent to.the system owner
and copies sent to.the buyer, if applicable,and the approving authority.
"""This report only describes conditions at the.time of inspection and under the conditions of use:
at that time.This inspection does not address how the system will perform in the future..under
the same or different conditions of use.
t5ins-11/10 Title 5 Officia In Pe i n Form:Subsurface Sewage Disposal.System-Page 1 of 17
Z �j
7
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 128 Oakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner Owner's Name
information is Hyannis MA 02601 January 31, 2013
required for every y ry
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:
® 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:
Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer
Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The
scope of this inspection is limited to health and environmental compliance and the septic system has
been evaluated according to the conditions observed on the day it was inspected. No estimate or
guarantee of system longevity is made or implied by a passing determination.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t
128 Oakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner Owner's Name
information is Hyannis MA 02601 January 31 2013
required for every rY
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes.(cont.):
❑ Observation of sewage backup or breakout 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 [1 ,N ❑ ND (Explain below): ,
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C} Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1., System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning.in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Y
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 128 Oakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner Owner's Name
information is Hyannis MA 02601 January 31 2013
required for every y ry
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
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
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
128 Oakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner Owner's Name
information is required for every Hyannis MA 02601 January 31,2013
page. CityfTown 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
0. obstructed pipe(s). Number of times pumped-
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 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-.
❑. 1Z10,000gpd.
ElThe 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
El '. 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
' r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 128 Clakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner Owner's Name
information is Hyannis MA 02601 January 31 2013
required for every y ry ,
page. Cityrrown 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
. 0 ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
El a 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.
® 0 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): 2 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd
t5ins•11110
Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal.System Form- Not for Voluntary Assessments
M 128 Oakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner Owner's Name
information is Hyannis MA 02601 January 31 2013
required for every ry
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Although two bedrooms were specified on the original design plan, sufficient leaching capacity for a
three bedroom dwelling was provided under the prevailing Title 5 regulations. Assesor's records
indicate a three bedroom dwelling.
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)): 2 gpd
Detail: ,
2011, 2012
Sump pump?
Yes 0 No
Last date of occupancy: October,2012
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 31 O.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-sanitarywaste discharged to the Title 5 system?9 y ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
GSM 128 Oakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner
Owner's Name
information is rY Hyannis MA 02601 January 31 2013
required for every � �
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other r'(describe below
General Information
Pumping Records:
Source of information: agent
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
128 Oakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner Owner's Name
information is Hyannis MA 02601 January 31 2013
required for every ry
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:
Age: 33+ years. Certificate of compliance for new system was issued 11/9/1979 (Permit#79-578 at
Health Dept).
- -
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2
Depth below grade: feet
Material of construction:
cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc:):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
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
Dimensions:
8.5x5x6- 1000 gallon tank
-
8 in
Sludge depth:
�
t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
M 128 Clakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner Owner's Name
information is Hyannis MA 02601 January 31 2013
required for every y rY
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 26 in
Scum thickness none
Distance from top of scum to top of outlet tee or baffle 10 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Design plan
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping is not required at this time. Maintenance pumping is recommended every 2-4 years. Tank
and tees appear structurally sound and functioning as intended.
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 Farm:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
t
M 128 Oakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner Owner's Name
information is Hyannis MA 02601 January 31, 2013
required for every rY
page. Cityrrown State Zip Code Date of Inspection
C
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: El 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
I ..
t5ins•1 ill 0 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
i
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 128 Oakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner Owner's Name
information is Hyannis MA 02601 January 31 2013
required for every y ry
page. Cityrrown 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 at outlet invert
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.):
D-box appears structurally sound with no evidence of leakage in or out. Some solids in sump.
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:
15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts -
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 128 Oakview Terrace
Property Address .
Joseph and Heghineh Yavanian
Owner Owner's Name
information is Hyannis MA 02601 Janus .31, 2013
required for every y ry
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ leaching chambers number:
❑ leaching galleries number:
❑ Teaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
i
❑ 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.):.
Soils above leaching pit appear unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into
leaching pit stone and no effluent contact staining was observed in the:stone or overlying soils. No
standing effluent was observed to a depth of 2 feet below the top of the peastone layer.
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
128 Oakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner Owner's Name
information is Hyannis MA 02601 January 31 2013
required for every y ry
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
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 Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
l -� Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form Not for Voluntary,Assessments
128 Oakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner
Owner's'Name
information is Hyannis
MA 02601 January 31, 2013
required for everyry
page. Cityrrown 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 tide boxes below:
hand-sketch in the area below
❑ drawing attached separately
Oj
N
t;
0
KU ► =Tz "ACLU} 2:
t5ins+.11/10. Title sotriciairnspec6onFarm:.Subsurface Sewage bisposalSystam Pa9e7J5667
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
128 Oakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner Owner's Name
information is Hyannis MA 02601 January 31, 2013
required for every y rY
page. CityrFown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
I�
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 15+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 8/30/1979
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:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Approved design plan on file'with the Board of Health shows bottom of system to be 4.75 feet above
the bottom of a witnessed test pit in which no groundwater was encountered. Town of Barnstable GIS
Department records indicate that the property is over 15 feet above groundwater table.
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 128 Oakview Terrace
Property Address
Joseph and Heghineh Yavanian
Owner Owner's Name
information is Hyannis MA 02601 January 31, 2013
required for every y ry
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information —Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
T.4W OF BA3tNSTp,BLE
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No.......... 7. ' -' Fss..L . �..._
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH -
710W..AJ..............OF...... ..................................
Appliration for Disposal Works Tonutrurtiun Prrutit
Application is hereby made for a Permit to Construct (� or Repair ( ) an Individual Sewage Disposal
System at: /
��� �ocat' Address or Lot No.
- G.',f __. ........ .� :. . Ar�°�----------------- ------r° _..�3u' sib ere rE,���.�t�.._....
,Qwner C� 5� e Address
!._. .....("... .... Alva ......................•--^..... --•-----..............--•--�....-•----•--••----...............................................
Installer Address
Type of Building Size Lot/0. L,5•-_5......Sq. feet
Dwelling—No. of Bedrooms___........................................Expansion Attic ( ) Garbage Grinder ODD)
Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures ----------
W Design Flow........... ....................gallons per day. Total daily flow........P�.�- ._gallons.
�i i 'el ��
WSeptic Tank—Liquid'capacity/ �P ..gallons Lengtl6.. _.____ Width ..... Diameter................ Depth.a...�.._
x Disposal Trench—No..................r"Width.....__......_...... Total Length.................... Total leaching area............__......sq. ft.
Seepage Pit No________ _______ meter.18. .?__-.__- Depth below inlet- -............ Total leaching area it .U_....sq. ft.
Z Other Distribution box Dosing tank ( )
'-' Percolation Test Results Performed byRON-AAb...A!t.�rsteX ...fZ!S...... Date...AV.6rr....�G?,�_o9�.�
Test Pit No. 1---4n .minutes per inch Depth of Test Pit.Z�._........ Depth to ground water-_& A81 .....
L� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a' •-••----•--•---------------------•--••-----•-••--••--•••-----•-----•----.........------•.....__.._......-------•-••=------•-••-•......_-----•----.........._.
0 Description of Soil........ 14. ---. �1T _d_.+ --;- '�-_.s .`�._ sQ.!� -._k5 �!
............ ------------•-•-----•--••----------------------------
V
W ••••---•-----------------------------------------•-----------.......-•----.........----.........---------------•---•-•-------•--------•-•---•---------------•...................._...........-------•---
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
............................... -••-••-•--•••----....-•-•-------•---...------•••--------------------•---•----------...----•---••----...••-•---•------•-----••-•-•--•-•-•-••-•-•--•--.............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT, . 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sigd . -----•-----------------•--•--•--------......... .----------------.........
Date
Application Approved By. `..7.-q..
Date
Application Disapproved for the following reasons:.....................
......
....................••---------..............................
----------•----------------•-----..................----------•-•-•--........----------.............-_---
Date
PermitNo.......................................................- Issued........................................................
Date
NO..........6'_.7 / F�a.. ..............
THE COMMONWEALTH OF MASSACHUSETTS 1-
yn.-e
BOARD OF HEALTH
1�...............OF...... ,!' R i�„>. .. ..
A plira#ilan for Disposal Works Tonstrnrtiun rnmit
Application is hereby made for a Permit to Construct (. or Repair ( ) an Individual Sewage Disposal
System at: ,
"Local Add res or Lot No w� 1'r
(� L/
•---......_4�.Z_`.'�.�_•__..._�.._... -,�..�.:�:----�/��......................... .......:....._..�...��_D..�.. �=-`:......_...--•---
Owner Address
a •-- ...... �.��0%y /1!'r ....................••••-----•. .................... _ ..........................................................
Installer Address
Type of Building Size Lot__- �.Z .� ------Sq. feet
Dwelling—No. of Bedrooms..............::__..........................Expansion Attic ( ) Garbage Grinder (104)
a'4 Other:--Type of Building No. of persons............................ Showers
YP g --------•--...-•-----••----- P ( ) — Cafeteria ( )
d Other fixtures -----•------------------------------- .... •---.........................
W Design Flow-----------.................................499 gallons per p son �r fla 5..y. Total daily flow..._... : -............._..gallon.
WSeptic Tank—Liquid'capacity/ta:" ..gallons Lengt .._�''1�+ .-_-. Width. .k,,0..:_. Diameter................ Depth., ..-.8.._
x Disposal Trench—No..................... Width..................Y. Total Length........ 0 Total leaching area-----_--___.......sq. ft.
Seepage Pit No........110*...._..,.Diameter.,`............. Depth below inlet............... Total leaching area_ .-_e2.Q...sq. ft.
z Other Distribution box Dosing,tank ( )
~' Percolation Test Results Performed by. bt9A.-_. ...A:Ar'& ?VJ_!... P!- .... Date...AA$.x---A jR A-Y
a
Test Pit No. I...4- _minutes per inch Depth of Test Pit..e;k......... Depth to ground water.. : .._..
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Pa' P ••-••----•-- t ............................ ....._ ............... ••--•--•••---•••-•- ---•-......---•..._.••-- ••--....--
O Description of Soil .--
WAu., :.... ..... ... ...... &V 4�.
x ---------------------------------=-------------•--------- .......................................-.....................................................................................................
U Nature of Repairs or Alterations;—Answer when applicable.............................................................................................
s Agreement:
The und6Fi igned ag'r"ees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE,
p 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
`., ; Signedi ---•...... .......................................•-•----•------..._..
Date
Application Approved B ""` �1/— k- t
PP PP Y----- p• s � ""
Date
Application Disapproved for the following reasons-------------•••-•-•--- ,--001 e....-------------------•---•-----------•----•-••-----------•--•--•-----•......_
---------•------------•---------------------•-----...- ......................------.........--------............_............---•---•...--------------------••------•----•--.....
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(9rdifirate of Tomptianrr
THIS I TO CERT FY That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by............. �Ql�....._-4P.. .................... .... ...._.. -------------
---------------------
-------------
...._....-------
at...........�-' ._..'••-•--.4•--- t�f i!.IV% !I!r..! =/� :.AV:taller t�
has been installed in accordance with the provisions of T T. j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit N ..._ ..._,�'��'�
--- --- -•--........ dated---.-�.�_._...,,��..-....7�;--------•
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE--.-•-• ..� /•,�I Z. .......... .-----...... Inspector!
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
� :
Disposal Vorkii Cnonirurtion rruttt
Permissionis hereby granted-----------------------------------------•--.--.....--•--•••--..._................._....-----•------......----.......---:...-----...........
to Construct,;) or tRepair ) an Individual SW age e Dis o a1.System
at No...............Z1r :�1..._ o/ �/�1� I�NI✓�,.Y ......................... -------- •.....•••--...._
.........
Str et "
as shown on the application for Disposal Works Construction P� �t,No _ ____________ Dated....?_"��'.��.-..c..... �'
,,��tt
/ t and of IF�Ith
DATE. f -�..1` .,
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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