HomeMy WebLinkAbout0055 OLD TOWN ROAD - Health 55 Old Town Rd
267-059 Hyannis
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
f
,..'' 55 Old Town Rd
M Property Address
AU Realty Corp4
Owner Owner's Name 4t
information is Hy annis Ma 02601 2/2/19 r..
required for every
page. City/Town State Zip Code Date of Inspection !a`$
Ste.f
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 8
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael DiBuono
use the return Name of Inspector
key.
DiBuono Sewer and Drain
K�yji
Company Name
35 Content Ln
Company Address
Cotu it MA 02635
Cityrrown State Zip Code
508-364-9587 S113522
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
2/3/19
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
55 Old Town Rd
Property Address
AU Realty Corp
Owner Owner's Name
information is
required for every Hyannis Ma 02601 2/2/19
page. Citylrown 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:
System contains a 1,000 gallon septic tank. As well as a concrete distribution box and 6x6 leach pit.
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.
PP
Ili 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 b the Board of
Health.
PP Y
*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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Old Town Rd
Property Address
AU Realty Corp
Owner Owner's Name
information is required for every Hyannis Ma 02601 2/2/19
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:
❑ 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
15ins•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
55 Old Town Rd
Property Address
AU Realty Corp
Owner Owner's Name
information is required for every Hyannis Ma 02601 2/2/19
page. CitylTown 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
55 Old Town Rd
Property Address
AU Realty Corp
Owner Owner's Name
information is required for every Hyannis Ma 02601 2/2/19
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.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form Not for VoluntaryAssessm As
sessments
M 55 Old Town Rd
Property Address
AU Realty Corp
Owner Owner's Name
information is
required for every Hyannis Ma 02601 2/2/19
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
❑ ® 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): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
- Title .5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 55 Old Town Rd
Property Address
ALJ Realty Corp
Owner Owner's Name
information is required for every Hyannis Ma 02601 2/2/19
page. CityrFown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: Vacant
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d Na
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occupancy: 2016
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 55 Old Town Rd
Property Address
AU Realty Corp
Owner Owner's Name
information is
required for every Hyannis Ma 02601 2/2/19
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: Not Provided
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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 55 Old Town Rd
Property Address
AU Realty Corp
Owner Owner's Name
information is required for every Hyannis Ma 02601 2/2/19
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
9/14/1990
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
System is vented through the roof
Septic Tank(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1000 gallon
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 117
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 55 Old Town Rd
Property Address
ALJ Realty Corp
Owner Owner's Name
information is required for every Hyannis Ma 02601 2/2/19
page. Cityrrown 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
24"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
42"
Distance from bottom of scum to bottom of outlet tee or baffle " Sludge stick
How were dimensions determined? Tape Measure
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 is normal. Pumping is Recommended
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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 55 Old Town Rd
Property Address
AU Realty Corp
Owner Owner's Name
information is required for every Hyannis Ma 02601 2/2/19
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
55 Old Town Rd
Property Address
AU Realty Corp
Owner Owner's Name
information is
required for every Hyannis Ma 02601 2/2/19
page. Cltyrrown 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 Level and at normal level
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, 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:
l5ins-3/13 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
55 Old Town Rd
Property Address
AU Realty Corp
Owner Owner's Name
information is required for every Hyannis Ma 02601 2/2/19
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.):
No ponding or break out
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
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 55 Old Town Rd
Property Address
AU Realty Corp
Owner Owner's Name
information is
required for every Hyannis Ma 02601 2/2/19
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
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM , 55 Old Town Rd
Property Address
AU Realty Corp
Owner Owner's Name
information is required for every Hyannis Ma 02601 2/2/19
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
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ,•°'� 55 Old Town Rd
Property Address
AU Realty Corp
Owner Owners Name
information is
required for every Hyannis Ma 02601 2/2/19
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 10+ ft
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
❑ a d of Health -
explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
USGS
You must describe how you established the high ground water elevation:
USGS Maps suggest groundwater to be 10+ ft below grade
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
3/4/2019 Assessing As-Built Cards
TOWN OF BARNSTABLE
LOCATION ES UCD (T) SEWAGE#
VILLAGE Mtc,aa,-.. a,—I-';&)ASSESSOR'S MAP G LOT
INSTALLER'S NAME G PHONE NO. Rt, PnT
SEPTIC TANK CAPACITY ` 060
LEACHING FACILITY:(type) f IY (size)?oo r
NO.OF BEDROOMS_3_PRIVATE WELL OR PUBLIC WATER�,164 i
BUILDER OR OWNER S y w.vt en t Jlnl t f of
DATE PERMIT ISSUED: gJl,'d(V
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
a'!x"
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https://townofbamstable.us/Departments/Assessing/Property_Values/HMdisplay.asp?mappar=267059&seq=1 1/2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, 55 Old Town Rd
Property Address
AU Realty Corp
Owner Owner's Name
information is
required for every Hyannis Ma 02601 2/2/19
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
I
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
y
�k L Commonwealth of Massachusetts
Executive Office of Environmental Affairs
y
,
Department of
Environmental Protection. c 2
William F.Weld , ' , �4rudy Coxe I
Governor s l �.8e1,1111ary,
Argeo Paul Celluccl 1d David B.Struts
u.Governor comndedoner
etc `
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
55 Old Town .Rd CERTIFICATION
Property Address: Hyannis Address of Owner. Sumner Wheeler
Date of Inspection: 7—9—9 6 (If different) 20 Caulfield DR
Name of Inspector. W.E. Robinson SR 508 )775-8776 Newton .MA 02159
Company Name,Address and Telephone Number.
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,actairate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sew disposal systems. The system:
Passes
_ Conditionally Passes
_ Need*Further Evaluation By the Local Approving Authority
_ Fails'
Inspector's Signature! , --- —�� Date: cti s
i
The System Inspector\shail,submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspection. If the sytiteihliis a shared system or has a design flow of 10,000 gpd of greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A,B, C,or D:
A) SYS PASSES:
w t violates an of the failure criteria as defined in 310 C 15. .
I have not found any information loch indicates that the system y MR 303
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes
j *pection-
Indic
to yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,cracked, structurally unsound, shows substantial infiltration or enfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved
by the Board of Health.
1_�/(revised 11/03/95) 1
One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292.5500
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 55 Old Town Rd Hyannis
Owner. Sumner Wheeler
Date of Inspection: 7—9—9 6
B]SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed ted pipe(*)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] FUR ER 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 the
public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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.
2) S TEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)
D THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
8 AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
3)
(revised 11/03/95) 2 ar
S i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 55 Old Town Rd Hyannis
Owner. Sumner Wheeler
Date of Inspection: 7-9-9 6
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
Backup of sewage into facility or system component due to an 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 leas than 1/2 day flow.
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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
ooliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LAR E SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
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)
The wrier or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
req ' merits of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information..
(revised 11/03/95) 3 t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 55 Old Town. Rd Hyannis
Owner Sumner Wheeler
Date of Inspection: 7-9-9 6
Check if the following have been done:
Pumping information was requested of the owner,occupant,and Board of Health.
I/None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. barge volumes of water have not been introduced into the system recently or as part of this inspection.
_A,built plans have been obtained and examined. Note if they are not available with N/A.
L/The facility or dwelling was inspected for signs of sewage back-up.
, /The system does not receive non-sanitary or industrial waste flow
L/e site was inspected for signs of breakout.
11 system components,excluding the Soil Absorption System, have been located on the site.
i/The septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or
tees,material of construction, dimensions,depth of liquid,depth of sludge,depth of scum.
✓The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
_4 "e facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-
surface Disposal System.
(revised 11/03/95) 4
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION
Property Address: 55 Old Town Rd Hyannis
Owner. Sumner Wheeler
Date of Inspection: 7_9_9 6
FLOW CONDITIONS
RESIDENTIAL:
Design flow j 3t 0 ns
Number of bedrooms:
Number of current residents:
Garbage grinder(yes or no):_ _
Laundry connected to system(yes or no):
Seasonal use(yes or no): it/
Water meter readings,if available:/
Last date of occupancy: Y
COMMERCIALANDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-aanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and urce of information:
System pumpWas part of inspection: (yes or no)_
If yes,volume pumped: gallons
Reason for pumping:
TYPE OF/SYSTEM
Septic twWdistn'bution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yea,attach previous inspection records,if any)
Other(explain)
r9 9 0
APPROXIMATE AGE of all components,date installed(if known)and source of information:
Sewage odors detected when arriving at the site: (yes or no) 14, O
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
Property Addrem 55 Old Town Rd Hyannis
Owner. Sumner Wheeler
Date of Inspection: 7—9—9 6
SEPTIC TANK:Y
(locate on site plan)
Depth below grade:
Material of construction:—concrete_metal_FRP—other(explain)
Dimensions: F `''
Sludge depth: 1 2- � ' .1
Distance from top of sludge to bottom of outlet tee or baffler
Scum thickness: 6 , v
Distance from top of scum to top of outlet tee or baffle:�j_
Distance from bottom of scum to bottom of outlet tee or baffie:Q'
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural iategrity,
evidence of leakage,etc.) C i' Z!04' C
G E TRAP:_
(loca on site plan)
Depth low grade:
Mate ' of construction:_ooncrete_metal_FRP_other(e:plain)
Dime ions:
Scum
from top of scum to top of outlet tee or baffle:
from bottom of scum to bottom of outlet tee or baffle:
Co nts:
(rood ndation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
eviden of leakage,etc.)
(revised 11/03/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 Old Town Rd Hyannis
Owner. Sumner Wheeler
Date of Inspection: —9—9 6
TIG R HOLDING TANK:_
(lo on plan)
Depth below
Material of n:_concrete_metal_FRP_other(e:pLun)
Dimensions:
Capacity: ons
Design flow: gallons/day
Alarm level:
Comments•
(condi' of inlet tee,condition of alarm and float switches,etcJ
DISTRIBUTION BOX:N
(locate on site plan)
Depth of liquid level above outlet invert:�Z
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP HAMBEIL
(locate o site plan)
Pumps' working order.(yes or no)
ts:
(note ndition of pump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 Old Town Rd Hyannis
Owner. Sumner Wheeler
Date of Inspection: 7-9-9 6
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
Type. leaching pits,number:_
leaching chambers,number:_
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
) /� r
Comments: (note condition of soil,signs of hyd;fiulic failure level of ponding,condition of vejMtation,etc.)
kei•pL
CESSPOOLS:
(locate site plan) }
Number d configuration:
Depth-top f liquid to inlet invert:
DL
' layerD layer:
D of cesspool:
Materials f construction:
Indicatio of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comore : (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY:
(locate on 'te plan)
Mate ' of construction: Dimensions:
Depth o solids:
Comme ta:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
(revised 11/03/95) 8
• • 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 55 Old Town Rd Hyannis
Owner. Sumner Wheeler
Date of Inspection: 7-9-9 6
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to groundwater ? �---r feet
method of determination or approximation:
(revised 11/03/95) g
TOWN OF BARNSTABLE
LOCATION SS oLTD `�nuo n SEWAGE #
VILLAGE "7--� ,ay' { ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. '�tf?tT j , d�
SEPTIC TANK CAPACITY 1 &a.11llS
s� p
LEACHING FACILITY:(type) p IT (size) I a cw r
NO. OF BEDROOMS 3 -PRIVATE WELL OR PUBLIC WATER?,�661
BUILDER OR OWNER -5J v,.✓I4^
DATE PERMIT ISSUED:
DATE COZIPLIANCEISSUED:
VARIANCE GRANTED: Yes No
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�1
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
o
Appliration for Bhip oal Workii Tongtrnrtinn Pr it I4`�
Application is hereby made for a Permit to Construct ( ) or Repair (-/) an Individual Se Dispos'a�
System at: )
Location-Address or Lot No.
a -- Owner , Address
—F
-•�OVe/ __...... .r. ii� ....... ..e
Installer Address
dType of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms___a?......................................Expansion Attic ( --) Garbage Grinder (to)
Other—Type of Building ..... No. of persons.......... ................ Showers — Cafeteria
Pa Other fixtures -----•-----------••- ---•---
-----------------------------------------------------
__---------------------------------•------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity4Q.CV__gallons Length9..Ia......... Width.!;-,r......... Diameter________________ Depth_.�i_'________-
x Disposal Trench—No_ ____________________ Width.................... Total Length..................... Total leaching area....................sq. ft.
Seepage Pit No_k,.0P_Q-------- Diameter-----6............. Depth below inlet__Ia.............. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) -
�" Percolation Test Results Performed by---_---------------------
--•---•-----------•------- --•-••-•---•-- Date........................................
a Test Pit No. I................minutes per inch Depth of Test -------------------
Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit_____:______________ Depth to ground water........................
.,,. .
Pd ..
Description of Soil..........)_8••........ .A. Sc?s.L ------- xk-- Z�i+eZAll. .
�.,
W -----••-•-•-------------•---•--•-••-•-•••--•--•••••---------------•--•---------•----••--••----•------ -------------=----•••--••••----------------------•---•------•-•-•--••--••-••--••--•----•--••-•----
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
-----•-•••-•--•••-•------•--•--------------•---•---------------•--••--••••-••--•--••-...............-•••-..........y..................=-----•-------------•------•---•--•-••-•-------•---•--••••-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliang has been is ued by the board of health.
Signed -----------------
Application Approved By . ---...--.. �7� ... j
-- --- (
>% ���.��d ! Dare
Application Disapproved for the following reasons- -------------------------------------......................... -----------------------------------------------------------------------
....................................................................................................................... - -
Permit No. 6 �." Q , --------- Issued ------------- ''�-- !�.-'- 9a--------
J
No._.................. FEE...........................
THE COMMONWEALTH OF MASSACHUSETTS ~
BOARD OF HEALTH '¢
TOWN OF BARNSTABLE l 1
Appliration for Diipuiittl Works Tontitrurtiutt' Vprmit 1—i
_---)
Application is hereby made for a Permit to Construct ( ) or Repair (X) an Individual was ge,Disposal-
System at:
_
.......... ...__--.__...........----- ....... ----•-- .................. ...................... ..._.......... - - - .................-..............
`Location-Address t or Lot No.
-e^ . 1aV�e cLe r
_ Owner Address
Q J
fl t X o rL f I J t Pe C
Installer Address #
d Type of Building Size Lot-------------•--------------Sq. feet
U Dwelling—No. of Bedrooms.._�?......................................_Expansion Attic ( ') Garbage Grinder (N, )
aOther—Type of Building ............................ No. of persons.........3.--------------- Showers (; ) — Cafeteria ( )
dOther fixtures ----------------------------------------•-•----....--•----------------------•--------------------------•-.....----------.....--•--------•---------•--
W Design Flow..........................._________________gallons per person per day. Total daily flow.................j..........................gallons.
9 Septic Tank—Liquid capacity.!-PA)-.gallons Length`:.�._...._._ Width Sit......... Diameter................ Depth..`/.,_.._..._.
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage,Pit No._1; q�?_� ....... Diameter.....6------------- Depth below inlet._............... Total leaching area..................sq. ft.
Z Other�Distribution box ( ) Dosing tank ( )
(Percolation Test Results Performed by.......................................................................... Date........................................
ate. ..
Test Pit No: 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
} L=, Test Pit`No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R4 ----------- ---------------------•------•-•--K— : -� ' tr
-------•-------------------•-•--------•----------•-------------•.......................................
O Description of Soil..........1
-16,- 4 —co Sot L " 8- /. :'1�JeeJVI^SQ✓(t� .
(� -------------------------------------------•---...... •----------------
-------------
---------------------------------------------------
-
1 W --•---------------------•-----------••-••--•--------......-•----------------------------------------------......----------------- ................•..............
U 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 TITLE 5 of the State Environmental 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 L ~%✓ -- � �
- ----- ----------------
Dj
t Application Approved BY --....... •I!".... ........!%--- ��. .1.'.�__1..fi...,vf ........................ �O
- Date
Application Disapproved for the following reasons:2....... �.
i
Permit No- ..............a.....:'."........ . .......... m Issued ------ ------- r'- 'Po e -a=
` Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
CPrttftrate of Conytiance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (
a
by - /J' .�PG'y�.e9. _kw ........ -------------------------------------------------------------..........................
.,�• Installer
at .-_.'"�-------------------• --, ------- ---.-!=�..���------.----�-- -------�........... ���_ .. ............ ----------------
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. .K....f�.'`..���. ' .... dated ... ` $
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
rr . // G C�c c�i L
DATE. f 1 ...�!- �.�------------------------------------------------------- Inspector -----------.--------------------------- ........................... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE '�_�
No...................... FEE...•-•••................
Disposal Vorks Tans#rudiatt Permit
Permission is hereby granted........... /�_.......r� '. AP �•`....................................................
to Construct (. ) or Repair (L)' an Individual Sewage Disposal System _ I
at No.------t . ''_ �` />L 1�' „G---•-----. 2 ,/!1:
----------------------------------
Street
as shown on the application for Disposal Works Construction Permit No.4 AA-,✓� Dated.._.....;7— '__.__/r..+.
............................................_
�j'\• �~ ...... Board ofo-Healfh`
DATEr ' --------------- -------
FORM 36508 HOBBS 6 WARREN,INC..PUBLISHERS ��