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LOCATION 36J
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SEPTIC TANK CAPACITY J 000 Cge-eY
LEACHING FACILITY.(type)`; (size) 1000
NO.OF BEDROOMS
OWNER
PERMIT DATE: CAE DATF--_ „; . Ia0 IO
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
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Commonwealth of Massachusetts o2 5 gg
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 383 Old Strawberry Hill Rd
Property Address k '
Michael & Katherine St Mary
Owner Owner's Nam
information is Hyannis Ma 02601 10/21/2017 -'
required for every y t=
page. City/Town State Zip Code Date of Inspection q_
ft�t
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return Name of Inspector
key.
Title V Septic Inspection
Company
Na
r� Company Name
74 Beldan Ln.
I Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com S14522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/21/2017
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.
l5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17
05�j GCS
Commonwealth of Massachusetts
N r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
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 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:
The dwelling located at 383 Old Strawberry Hill Rd Hyannis. is served by a Title V septic system
consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon precast leach pit.
The system was found to be in proper working condition at the time of inspection.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health;will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 official Inspection form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,..'( 383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ 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:
I
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
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 Y2 day flow
t5ins•3/13 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
383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5lns-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
f
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
R M 0 383 Old Strawberry Hill Rd
b
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: vacant
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-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M " 383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
u r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,•' 383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
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:
system original, 1983 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
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.):
Joint were ok, no leaks, vented through the roof
Septic Tank(locate on site plan):
8"
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: 1000 gallons
Sludge depth:
3"
Lmns /13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
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
4'
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
10"
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? opened covers, took
measurements
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
water level was slightly below outlet invert, most likely due to evaporation. tank was structurally
sound, Tank does not need to be cleaned now but should be done every 2 years for proper
maintenance.
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
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
page. Cityrrown 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M �y 383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
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.):
Distribution box was in good condition, no rot, water level was even with outlet invert.
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:
t5lns-3/13 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 383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit was found to be dry with a stain line only 1'from the bottom. Cover is 16" below grade.
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 Forth:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a a` 383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
I
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
V0'y� 383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
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 the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
C
'Coll L
1AN4
37 p 4 03
61 zo
,AZ 3Z
13Z zs
p..13o>L
,A3 Uy
135 31 y
y 311
t5ins-3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, 383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
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: 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 established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
L
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
~ 383 Old Strawberry Hill Rd
Property Address
Michael & Katherine St Mary
Owner Owner's Name
information is required for every Hyannis Ma 02601 10/21/2017
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is Hyannis MA 02601 May 20 2010
required for State Zip Code Date of Inspection
every page. City/Town
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the I I lt/Uf�
computer,use 1. Inspector:
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return key. Se tic Inspection Services Co.
Company Name
189 Cammett Road
Company Address
Marstons Mills MA 02648
renm State Zip Code
City/Town
S11285508.428.1779 Li
Telephone Number Lcennsese Number u
B. Certification
I certify that I have personally inspected-the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
LU CCU
{ m :T- \ May 20, 2010 Job# 10-138
C� Date
In ector's Signature
C/) F—
The system inspector shall submit a copy of this inspection report to the Approving Authority (Boar
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
°° rn has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
I U- report to the appropriate regional office of the DEP. The original should be sent to the system owner
zand copies sent to the buyer, if applicable, and the approving authority.
o****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.
Title 5 Official Inspection Form:Subsurface -age Disposal System•Page 1 of 17
t5ins-09108
Commonwealth:of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is Hyannis MA 02601 May 20 2010
required for State Zip Code Date of Inspection
every page. Cityrrown
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:
Tank is,not in need of pumping at this time, leaching pit was found empty with no sidewall stains.
i
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):
Title 5 official Inspection Form:Subsurface Sewage Disposal system-Page 2 of 77
t5ins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is required for Hyannis MA 02601 May 20, 2010
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is Hyannis MA 02601 May 20, 2010
required for y
State Zip Code Date of Inspection
every page. Cityrrown
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
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_day flow
t5ins•09/08 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
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is required for Hyannis MA 02601 May 20, 2010
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a 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.] i
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
l
Commonwealth of Massachusetts
: Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is Hyannis MA 02601 May 20 2010
required for
every page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth.of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual):
2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is Hyannis MA 02601 May 20, 2010
required for y
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
0
Number of current residents:
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
More than one
Last date of occupancy: month ago.
9
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•09108 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.'' 383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is Hyannis
MA 02601 May 20, 2010
required for y
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: None available.
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-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is Hyannis MA 02601 May 20, 2010
required for y
every 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:
Compliance date: 3/14/83
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
1'
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.):
Septic Tank(locate on site plan):
6"
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
8.5' long x 5.2'wide- 1000 gal.
Dimensions:
211
Sludge depth:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is required for Hyannis MA 02601 May 20, 2010
every page. Cityfrown 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
28"
Scum thickness Trace
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
13"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level was found at bottom of outlet invert, baffles were intact and clear. Tank is not in need of
pumping at this time.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal El 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 o1 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is Hyannis MA 02601 May 20, 2010
required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ 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
I
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is Hyannis MA 02601 May 20, 2010
required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
1.
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.):
No solids or high stains present liquid level at bottom of single outlet pipe.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is Hyannis MA 02601 May 20, 2010
required for y y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: One 6x6 pit.
❑ 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.):
Leaching pit was empty at time of inspection, observed no sidewall stains in pit indicating pit had
never had standing water.
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
15ins-09/08 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
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is Hyannis MA 02601 May 20, 2010
required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is Hyannis MA 02601 May 20, 2010
required for State Zip Code Date of Inspection
every page. Cityrrown
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
❑_ .d...rawl_ng attached senaratelV
Old Strawbe rry Hill Road
ater
ervice
77
3,,, 83
I /N %/%/%1N/%/1 I I'll,
37 20
"'N
34 42
q.k
' l
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is Hyannis MA 02601 May 20, 2010
required for y y
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 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:
USGS topo map and town GIS.
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water below el. 30 and topo map shows property at el.60.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
II
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
383 Old Strawberry Hill Road
Property Address
McIntyre
Owner Owner's Name
information is y
required for y H annis MA 02601 May 20, 2010
every page. Cityfrown 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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
L O CATION S G E PERMIT NO.
ZVILAG
IMS A ER'S tlAME ADDRESS
1 L O A OR OWNER
DATE PERMIT ISSUED - 4
OAT E C0 M P L I A N C E ISSUED ����
0
a
M
L0CA I.�Rf � SEWAGE PERMIT NO.
VILLAGE
1/q �-,
INSTA LLER'S NAME & ADDRESS
A-Y
BUILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE IS.S.U,ED ,aI` `pia
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toT 61 S'��rauo t-trri' !Lk 3 /�
`VILLAGE
INSTALLER'S NA III E i ADDRESS
Arc
IOUILDE R OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
L
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11
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r
No.... "/�... Fizz.......4°............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............Town.................OF.......Barnstable
,P'10 Awiration for Dhiposa1 Works Cnnnuitrnr#uan f ermi#
Application is hereby made for a Permit to Construct (X ) or Repair ( } an Individual Sewage Disposal
System at:
..........� _.. ... ...- Old Strawbera..Hill. RdyMnis ..-MA-------•-•-•--•.......................................................
---------- •. s
Location-Address or Lot No.
Capr c.Q n... alt x. . .... ............... ......7.65 .................
W T , o Address
a ............................. .................. .......................... .................................... '•......................................................
Installer Address
dType of Building Size Lot...............0............Sq. feet
U Dwelling—No. of Bedrooms...........3...............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building MnCh.............. No. of persons............................ Showers (2 ) — Cafeteria ( )
Q' Other fixtures ----------------------------------
W Design Flow............. 5.........................gallons per person$per�day. Total daily flow.._..........3.3D.......................galll ns.
R� Septic Tank—Liquid"capac>ty1000--gallons Length................ Width._.A.1.0. biameter..._.._......... Depth. .............
W Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x
Seepage Pit No...... Diameter.......6.......... Depth below inlet_._6.............. Total leaching area.......266..sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed b Eldredge---Engineering---•--•--• Date..1.1-2.........................1
Y------•...-
0_a Test Pit No. 1.�.�JJ...Q....minutes per inch Depth of Test Pit___-1/.2.__....... Depth to ground water�7nMe...e.1�.COunter�-
CLI Test Pit No. 2.N/-A--.--.minutes per inch Depth of Test Pit:N1.-�.......... Depth to ground water---------N1A
e
� --------------------------------
•-------------------------------------------
*...........
..........
.----•-•-•--------............------------------
...--.-----
O Description of Soil------•-----0.1.........2_'.........1.Q.�ID.. c...taps.0 1...---•----------•-••---------------------------•----•-----------------...........---
U
W ---------------------------------------- U....-----12- me_d....`rthi.te----sand./__traces...o�'_..g�'a.Y_el/nQ---Watex_..at 12 '
UNature 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 T1 II.Ti LEE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliai h�issuedhe�boar of health.
Signe .... .......... ................�1 S 3/7./83......
..
_ Date
Application Approved BY---------------- •` i/� � ............................... ---
Date
Application Disapproved for the following reasons:....................................................------------------------------------------
••-•--------------•••-•••...---------•--.....---.._..--......-•-•---•----•------•----••............--••----------••.._.....--•-------------------••------•-- --
PermitNo................................•--•-------------....... Issued--------------------------Ad
Date
,R
No—emf.Gv... Flzs...... at_ .............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............Town..............._OF........Barnsta-ble.....................-----•--....................
Appliration for Disposal Works Tonstrnrtion Prrmit
Application is hereby made fora Permit to Construct (X) or Repair ( ) an Individual Sewage Disposal
System at:
61 — Old Strawberrl! Hill Rd...f.._H�.Brixu.8,...ML ................
Location-Address or Lot No.
...........Capxicarn..F,ea1ty---xxust------------------------ ....... b5---Fa]=uth...Road-r---Hy-- US.......--------..
Owner Address
a ...........$t.Ye...Le ... ................................................... ---------------------.....----.......................................••--•-.....--•--••----.......
Installer Address
Q Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............ .............................Expansion Attic ( ) Garbage Grinder ( )
a
P4 Other—Type of Building ranch.............. No. of persons............................ Showers (2 ) — Cafeteria ( )
Q' Other fixtures ............................................ I
W Design Flow.............. .5....................._..gallons per person per day. Total daily flow____-..------- 30......................gallons.
R: Septic Tank—Liquid capacityl.00.0gallons Length_$1.6_:.... Width-__.4.'10'1)iameter................ Depth.51.$"....
Disposal Trench—No..................... Width.................... Total Length.:.................. Total leaching area....................sq. ft.
Seepage Pit No................... Diameter........6........ Depth below inlet.... '....._._... Total leaching area.......26.6..sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results , Performed by...... 1dred�p..E.n veering.......... Date-_1:Ln?_$-j6S---------------
a Test Pit No. 1. 2..D....minutes per inch Depth of Test Pit.....1.2__....... Depth to ground_ waternone...encountee —
Test Pit No. 2. 1A.._..minutes per inch Depth of Test Pit._N�.A..__...... Depth to ground water.........jg/�,_.___.
P4 ----------•-------------•-••--••--------•------------------------------................................._......----•----------------------------...........--
O Description of Soil.............. ?=.........loam.--&---topsai.l.......................................................................................
x ..............................................2`__:-:.:10'_._.__mediM..yellow...sand. .--:_
W ---------------------------- .. 10'...-.A2-'......mad..---whita...aandltracoa: of-.graye1./na__water...at 12'
UNature 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 TIT12 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.
Signed.........................................................................Pres.. -_3./1./83.............
Date
Application Approved B
Date
Application Disapproved for the following reasons:................................................................................................................
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS 1
BOARD OF HEALTH
...............�Town..............
.....................................................
Tntifirattof,(tout, Ramp.
THIS IS T01:CERTIFY;r'That-the"Iiidiyidual Sewage Disposal System constructed ( X).`or Repaired
Stever:Lebe ..
Installer
at.......Lot...#--61....--.01d...Strawberr -- iR H�anni H _ s
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described-in the
application for Disposal Works Construction Permit No. ',,/ t.................. dated.................................................
THE ISSUANCE OF;THIS CERTIFICATE SHALL NOT BE CONSTRUE® A GUARANTEE THAT THE
` SYSTEM WILL F ZCTJQNSATISFACTORY.
DATE=::,::" :✓. :, ............................................... Inspector......... ------ -------------------------------------••------•--........-----•---
y W
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF EALTH
' Town ' Barns able
....................OF................... S.......................................................... �
No '..?':_ 7�..... FEE-- ...............
Disposal Works Tn , nnction rrm'
Permission is hereby granted----------- ----- ------ --.........C ��...........
to Construct ( X Repair (( l an Individual Sem,,a a Disposal System
at No...__.Lot #...�`� — O. Strawberry Hi l Rd..,................... Hyannis,_--MA- ------
------------------------------------------------------.- ---------•-••-•---•...
Street
as shown on the applica 'on for Disposal Works Construction Permit No..................... Dated..........................................
oa of Health
DATE.�. �3
FORM 1255 HOSES & WARREN, INC., PUBLISHERS
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®1�L� 125.00 (� F�L�
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LEGEND CERTIFIED PLOT PLAN
EXISTING - SPOT ELEVATION Ox0 1" 0
EXISTING CONTOUR --- 0 --- LOT LI - Si�f'tW E�'f~'`� HiL.L "-_,AD
FINISHED SPOT ELEVATION �_j i S
FINISHED CONTOUR 0 - PHI --
INBERG I N
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APPROVED , BOARD OF HEALTH o .pSAIIAS
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�sS�ONAL LN6
GATE AGENT SCALE, I ' = 4� DATE d2• 14. 03.
LDREDGE ENGINEERING IN CLIENT... I CERTIFY THAT THE PROPOSED
rh-EGISTE RE REGISTERED JOB N0, t'5 r1 . BUILDING SHOWN ON THIS PLAN
CIVIL LAND Q.�. CONFORMS TO THE ZONING LAWS
ENGINEER RV DR.'py------- OF BARNSTABI , MASS.
712 MAIN STREET. CH. BY
HYANNISI MA*S. [SHEET I OF ti DIATE LAND SURVEYOR
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