HomeMy WebLinkAbout0126 OLD TOWN ROAD - Health '1f26 Old Town*Road,
Hyannis F/R
A� 268' 082 i
e
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TOWN RF B-ARNSTABLE
LOCATION
0 SEWAGE # :;;?"-3>
VILLAGE Nr Ofi✓6 ASSESS MAP & LOT aZ6 cY' dCY�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Z
LEACHING FACIL=: (type) 1446 (size)
NO.OF BEDROOMS
BUILDER OR OWNER / e2C-°
PERMITDATE: °2l�3 COMPLIANCE DATE: S b D
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
Furnished by
ilb
Chi rD
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINAL (S)
im ^ �
DATA
Commonwealth of Massachusetts
Title 5 Official Inspection Form
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Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
126 Old Town Rd
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is required for every Hyannis! MA 02601 7/15/13
page. Cityrrown� State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out fortes A. General Information
on the computer, �` `
use only the tab 1. Inspector:
key to move your
cursor-do not Jason P Burnie
use the return Name of Inspector
key. i
Neighborhood Waste Water
ICI Company Name
350 iMain St
Company Address
Yarmouth MA . 02673
Citylfown State Zip Code
508J75-2820 S150.11
Telephone Number License Number
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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 idisposal 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
EJ 'Needs Further Evaluation by the Local Approving Authority
7/15/13
Inspector's Signature Date
The jsystem 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 la 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.
****Thief 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.
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
126 Old iTown Rd
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is required for every H yannlS
i MA 02601 7/15/13
page. City/Town! State Zip Code bate 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:
All clomponents were found to ben good working order. The septic tank inlet cover is 1'4"deep. The
outlet cover is 2'4"deep. The distribution box cover is 2'deep..The SAS is 4'deep and has a vent for
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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. -
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*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 than20 years old is available.
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❑ Y ❑ N ❑ ND(Explain below);
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
126 Old!Town Rd
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is H annisl MA, 02601 7/15/13
required for every y
page. City/Town State Zip Code bate of Inspection
B. Certification (cont.)
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❑ 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):
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❑ 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):
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❑ The system required-pumping more than 4 times a year due to broken or obstructedpipe(s).The
Y q Y
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):
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C) Further Evaluation is Required by the Board of Health:
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❑ 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.
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1. System will pass unless Board of Health determines in accordance with 310 CMR
5.303(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
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❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments
i
126 Old jTown Rd
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is required for every Hyannis; MA 02601 7/15/13
page. Cityrrown State Zip Code Date of Inspection
B. Ce'rtification (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
j100 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:
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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.
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3. Other:
D) System Failure Criteria Applicable to All Systems:
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Youl must indicate"Yes"or"No"to each of the following for all inspections:
Yes. No
`El ® 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
I❑ ® due to an overloaded or clogged SAS or cesspool
j❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
I❑ ® Liquid depth in cesspool is less than 6°below invert or available volume is less
than '/day flow
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
126 Old(Town Rd
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is
required for every Hyannis MA 02601 7/15/13
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:
1❑ ® 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
f❑ ® tributary to a surface water supply.
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I❑ ® . Any portion of a cesspool or privy is within a Zone 1 of a public well
10 ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
I❑ ® 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
i 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-
4❑ ® 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 .
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❑ the system is within 400 feet of a surface drinking water supply
0 ❑ the system is within 200 feet of a tributary to a surface drinking water supply
I 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.
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
't o 126 Old(Town Rd
Property Address
Mary Gorbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is required for every Hyannisi MA 02601 7/15/13
a e, CityrrownI State Zip Code Date of Inspection
P9 P P
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
❑ Z Were any of the system components pumped out in the previous two weeks?
Z ❑ Has the system received normal flows in the previous two week period?
i Have large volumes of water been.introduced to the system recently or as part of
® this inspection?
El ® Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
0 ❑ Was the facility or dwelling inspected for signs of sewage back up?.
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❑ Was the site inspected for signs of break out?
❑ Were all system components,excluding the SAS,located on site?
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❑ 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?
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Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
l The size and location of the Soil Absorption System (SAS) on the site has
` been determined based on:
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0 ❑ 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
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i. approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
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Residential Flow Conditions:
Number of bedrooms(design): 4. Number of bedrooms (actual): 4
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DESIGN flow based-on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): SAS@
443gpd
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
126 Old Town Rd
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is required for every Hyannis! MA 02601 7/15/13
page. Citylfownl State Zip Code Date of Inspection
D. System Information
Description:
System consists of a tank, d-box and 6 plastic infultrators
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Nu I ber of current residents:
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Does residence have a garbage grinder? ❑ Yes ® No
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Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seat onal use? - ® Yes ❑ No
Water readings, if available last 2 ears.usage d 0 used since
i 9 ( y 9 (gP )) 2010
Detail:
HouIse has been vacant for appx 3 years.
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Sump pump? ❑ Yes ® No
Lasti date of occupancy:. Appx 3 years agoDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based.on 310 CM 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 Form:Subsurface Sewage Disposal System•Page 7 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
I
126 Old,Town Rd
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is required for every Hyannis MA 02601 7/15/13
page. CityrrownI State Zip Code Date of Inspection
D. System Information (cont:)
Last,date of occupancy/use: Date
Other(describe below):
i General Information
Pumping.Records:
Source of information: No records available per Barnstable BOH
Was system pumped as part of the inspection? ❑ Yes ® No
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If ye`s, volume pumped: gallons
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How was quantity pumped determined? .
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Reason for pumping:
Type of System:
Septic tank, distribution box, soil absorption system
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❑ Single cesspool
❑ Overflow cesspool
❑I Privy.
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❑ 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):
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
126 Old Town.Rd
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is
required for every Hyannis MA 02601 7/15/13
page. Citylrown� State Zip Code Date of Inspection
D. System Information (cont:)
Approximate age of all components, date installed (if known)and source of information:
2003 per plan on file at the Barnstable BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on.site plan):
3'
Depth below grade:
feet
Material of construction:
❑cast iron ZA0 PVC El other(explain):
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Distance from private water supply,well or suction line: feet
Comments(on condition of joints, venting,evidence of leakage,etc.):
We ran a sewer camera up the line and it was ok at the time of inspection.:
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Septic Tank(locate on site plan)r
Depth below grader Inlet cover
Outlet cover-2'4"
feet
Material.of construction:
Z concrete ❑ metal ❑fiberglass ❑ polyethylene D other(explain)
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If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes ❑ No
Dime nsions:
1500ga1
Sludge depth: 211
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
126 Old iTown Rd
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is required for every Hyannisl MA 02601 7/15/13
page. CitylTownI 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 2+
011
Scum thickness
Distance from top of scum to top of outlet tee or baffle
4..+
I 1 +
Distance from bottom of scum to bottom of outlet tee or baffle
tapemeasure
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The!tank was found to be in good working order and has baffles in place.
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:Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction`.
El concrete ❑metal ❑fiberglass ❑polyethylene ❑other(explain):
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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
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t5ins•3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
126 Old ITown Rd
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is required for every Hyannis) MA 02601 7/15/13
page. CityrrownI State Zip Code Date of Inspection
D. Syi tem Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,
liquii 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):
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Dimensions:
Capi city:
gallons
Design Flow: gallons per day
Alarm present: El Yes ❑ No
Alarm level: .Alarm in working order: ❑ .Yes ❑ No
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Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
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*Att i`ch copy of current pumping contract(required).is copy attached? ❑ Yes ❑ No
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
yt 126 Old Town Rd
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is I
required for every Hyannis! MA 02601 7/15/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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Distribution Box if resent must be opened) locate on site plan):
( P P ) ( P ).
Depth of liquid level above outlet invert
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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.):
The box was found in good working order at the time of inspection.The cover is 2' deep.
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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.):
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*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 SiS not located, explain why:
SAS was located
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
't 126 Old(Town Rd .
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is
required for every Hyannis! MA 02601 7/15/13
page. City/Towni State Zip Code Date of Inspection
D. System Information (cont.)
Type: .
❑ Teaching pits number:
i 6-plastic
® leaching chambers number: infultrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields . number, dimensions:
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❑ 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.):
The iinfultrators were found to be dry at the time of inspection.
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Ces'pools (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
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Commonwealth of Massachusetts
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Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
"t a 126 Old(Town Rd
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is
required for every Hyannis MA. 02601 7/15/13
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.y,:
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Privy(locate on site plan):
Materials of construction:
Dimensions
Deplh.of solids.
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
126 Old Town Rd
Pperty Address
Mary Garbauskas 69 Neptune Ln W Yarmouth MA}02673
Owner Owner's Name
infOR1atiOn is Hyannis MA 02601 7/16/13
required for State zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
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t5ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 15 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'( 126 Old!Town Rd
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is required for every Hy annisl MA 02601 7/15/13
page. City/Townl State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water.
® Check cellar
®'Shallow wells
Esti I ated depth to high groundwater: f 0�+ per plan on file dated 2003
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Please indicate all methods used to determine the high ground water elevation:
® I Obtained from system design plans on record
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If checked, date of design plan reviewed: 2003 on file at the Barnstable BOH
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ I Checked with local Board of Health-explain:
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❑ Checked with local excavators,installers-(attach documentation)
® Accessed USGS database-explain:.
MIW-29 'Zone B water level 7.3 2.1x12=2'1"adjustment
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You''must describe how you established the,high groundwater elevation:
*****,*'SEE ATTACHED ENGINEERS.LETTER*******
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Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13, Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
tel.(508)362-4541
939 main street rt 6a tax(508)362-9880
yarmouth port
mass 02675 down cope engineering
civil engineers& land surveyors
structural design
Arne H.Ojala P.E.,P.L.S.
Daniel A.Ojala,P.L.S.
Timothy H.Covell,RL.S.
and court
surveys
site planning
May 6, 2003
:swage system
fesigns
Thomas McKean, RS
nspections Barnstable Board of Health
367 Main Street
germ its Hyannis, MA 02601
Dear Tom:
On May 6, 2003 Down Cape Engineering, Inc. performed an
inspection of the septic system at 126 Old Town Road, West
Hyannisport.
This is to certify that the septic system was installed in
substantial compliance with the approved plan. If you
have any questions, please do not hesitate to call me.
Yours trul ,
Arne H. Ojala, PE, PLS
Down Cape Engineering, Inc.
cc: Cheryl Kelly
Rodger Roberts
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
HAN
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
126 Old!Town Rd
Property Address
Mary Garbauskas 69 Neptune Ln W.Yarmouth MA 02673
Owner Owner's Name
information is required for every Hy annisi MA 02601 7/.15713
page. Cityrrowni State Zip Code Date of Inspection
E. Report Completeness Checklist
I
® Inspection Summary:A, B, C, D,:or E checked
k
® Inspection SummaryD (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
I
® Sketch of Sewage Disposal System either drawn on page.15 or attached in separate file.
I
f
i
-t5ins•3/13 i Tile.5.Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
r
i
{
No. "' 1 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppYicatton for Oiopozal *pe;tern Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade(�bandon( ) Pi�Qmplete System ❑Individual Components
Location Address or Lot No. `�o� 0((,N Ownerr''si,Name,Address and Tel.No.
Assessor's Map/Parcel7/_0,- �3'1 V,I C
yl-
Installer's Name,AdAress,and Tel.No. 77 Tl F Cfb Designer's Name,Address and Tel.No.
�T✓ev►-rt,��i �v ,,,,j, . � "^ r ( �-Sly((
Type of Building:
Dwelling No.of Bedrooms �'�r3�t,q, Lot Size sy.ft. Garbage Grinder( )
Other Type of Building / No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow L4\-1 0 gallons per day. Calculated daily flow
I gallons.
Plan Date Ld—X—0 Number of sheets Revision Date
Title
Size of Septic Ta 4 A I Type of S.A.S. 1 Xr-f-/11
(.f vtiQU��
Description of Soil L-0!A'11!�ac S Parr IMetQ E o ShKn
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected: DESIGNING ENGINEER MUST SUPERVISE
Agreement: INSTALLATION AND CERTIFY IN WRITING
A
g THE SYSTEM WAS INSTALLED IN STRICT
The undersigned agrees to ensure the construction and maintenance 9k ®#Dp.gftdTi®"site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by is Board
Signe A Date 5 d 3
Application Approved by Date —CJ,3
Application Disapproved for Ze following reasons
Permit No. 2 00? Date Issued —� �Q 3
I ----------------------
No. a ` ae� .r.}. Fee _
Entered in computer:
r _, THI�iCOMMONWEALTH OF MASSACHUSETTS Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS.
` ricaton forigoarpgtem �ongtructfonerntit
Application for a Permit to Construct( )Repair( .)Upgrade(V�`Abandon( ) mplete System ❑Individual Components
Location Address or Lot No.1 ���ptt,N p Owner's Name,
N'•ame,Address and Tel.No.
Assessor's Map/Parcel
Installer's Name,A04ress,aand Tel.No.o Designer's Name,Address and Tel.No.
-Du.Vemss T Jam. Ccq
g7 Tvek_r�
Type of Building: f
/� t
Dwelling No.of Bedrooms (4e viA. ,x Lot Size sq.ft. Garbage Grinder( )
Other i Type of Building / No.of Persons Showers( ) Cafeteria
Other Fixtures
jj
Design Flow `7,�0 ' gallons per day. Calculated daily,flow gallons.`
Plan Date Z U Number of sheets Revision Date
Title Size of Septic TA r.v Type of S.A.S. XV-f-1LTV f-AU'0
_Vf-AU'0
Description of Soil Ln jA. Foe__ S14v,0
Nature of Repairs or Alterations(Answer when applicable) �✓ /9(C id C
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been-i-ss�u�ed by is Board f He lth.
Signed 1 / Date S 1?, 6
Application Approved by nq Date 3
Application Disapproved for?he following reasons '
Permit No. yo 3- N Date Issued 03 4
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded(y�
Abandoned( )by e S C L
at a(0 D1 WtJ VQA 5- c,n-ti, Tas been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 0 3-/ dated
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the srewill function esi . ed.
01
P g Yg�Date �I WJ 3 Inspector
------------ --- —
No.
7-O0 � I / — Fee �Jr/ �'.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwi5pogai *pgtem Congtruc ' n Permit
Permission is hereby granted to Construct( )Repair( )Upgrade(-")Abandon
( )
System located at d 'D �
v
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date:_ S -a Approved by P) II nr- " e�.
V y
TOWN F BARNSTABLE
LOCATION ��` 0 SEWAGE# ���`
VILLAGE •.
� ill✓d ASSESS MAP &LOT
f INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY J L ! f
LEACHING.FACILITY: (type) 14ze jK (size) �{
NO.OF BEDROOMS
BUILDER OR OWNS / °�'�---PERMTTDATE: � ° 03 COMPLIANCE DATE: E4�
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 Feet
within 300 feet of leaching facility)
Furnished by
< < a
A14—
c,
d
tel.(508)362-4541
.939 main street rt 6a fax(508)362-9880
yarmouth port i ,�,,//
mass 02675 NoW/? Cdpe engineering
civil engineers& land surveyors
structural design
Arne H.Ojala P.E., P.L.S.
Daniel A.Ojala, P.L.S.
land court Timothy H.Covell,P.L.S.
surveys
site ptanning
May 6, 2003
sewage system
designs
. Thomas McKean, RS
inspections Barnstable Board of Health
367 Main Street
permits Hyannis, MA 02601
Dear Tom:
On May 6, 2003 Down Cape Engineering, Inc. performed an
inspection of the septic system at 126 Old Town Road, West
. Hyannisport.
This is to certify that the septic system was installed in
substantial compliance with the approved plan. If you
have any questions, please do not hesitate to call me.
Yours trul ,
Arne H. Ojala, PE, PLS
Down Cape Engineering, Inc.
cc: Cheryl Kelly
Rodger Roberts
IVED
TROY WILLIAMS MAR 0 4 2003 P�
o
SEPTIC INSPECTIONS
TOWN OF BARNSTABLE �S"3,7.b. 0
Certified by MA Department of Environmental Protection (508) 585-1300
19 Hummel Drive
South Dennis, MA 02660
-\ COMMONWEALTH OF MASSACHUSE17S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
f �
�J •
"TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION, w` �Cl,o1A
Property Address: 126 Old Town Road ` C®,,�0��
Hyannis,MA
Owner's Name: Cheryl Kelly
Owner's Addres.. 1701 St.Andrews Court
Boulder Ciy,NV 89005 ® v
Date of Inspection: February 5,2003
Name of Inspector: TroyM. Williams v
Company Name:
Troy Williams Septic Inspections
Mailing Address: 19 Hummel Drive
Telephone Number: South Dennis,MA 02660
(508)385-1300
CERTIFICATION STATEMENT
1 cenify 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. 1 am a DEP
appros ed system inspector pursuant to Section 15.340 of"I itle S(310 C MR 15.000). The systcm
Passes
Conditionally lasses
T Needs Further Evaluation by the Local Approving Author n�
Fails
Inspector's Signature: Date: a j,S-- /0 3
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth 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.
Notes and Comments
Although system meets the minimum requirements set forth by the Massachusetts Department of
Environmental Protection,certification is not to be construed as a guarantee of future working condition
of system,piping or components. This inspection represents the conditions of the system on the Date of
inspection noted above.
A'►'This report only describes conditions at the time of inspection and under the conditions of use'at that
time. phis inspection does not address how the system will perform in the future under the same or different t
conditions of use.
Title 5 Inspection Form 6/15/2000 paee I of 11
Page 2 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
126 Old Town Road
Owner: Hyannis,MA
Date of Inspection: Cheryl Kelly
February 5,2003
Inspection Summary: Che"k A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
1 have not found any information which indicates that y of the failure criteria described in 310 CNIR
15.303 or in 310 CMR 15,304 exist. Any failure criteria n evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be rep ed or
repaired. The system, upon completion of the replacement or repair,as approved by the Board of 1 lth,will pass.
Answer yes, no or not determined(Y,N,ND)in the for the following statements. If" of determined"please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whet r metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is i intent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by t oard of Health.
*A metal septic tank will pass inspection if it is structurally sound, leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break o or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled never distribution box. System will pass inspection if(with
approval of Board of health): ,
br en pipe(s)are replaced
bstruction is removed
_ distribution box is leveled or replaced
ND explain:
The syst required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspect if(with approval of the Board of Health):
I
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM '
PART A
CERTIFICATION(continued)
Property Address:
126 Old Town Road
Owner: Hyannis,MA
Date of fropection: Cheryl Kelly
February 5,2003
C. Further Evaluation is Required by the Board of Health:
Cunditiuns 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 „ill pass unless Board of Health determines in accordance with 310 CMR 15.303(1 )that the
system is not functioning in a manner which will protect public health,safety and the en ronment:
_ Cesspuol 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 m sh
2. System will fail unless the Board of Health(and Public Wale upplier,if any)determines that the
System is functioning in a manner that protects the public bea
safety and environment:
The system has a septic
— p tank and soil absorption s ern(SAS)
surface �satcr supply or tributary to a surface water pply. S)and the SAS is within 100 feet of a
_ The system has a septic tank and SAS the SAS is within a Zone 1 of a public water supply.
_._ The sN strm has a septic tank and S and the SAS is within 50 feet of a private water supply well.
The system has a septic to and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**. ethod used to determine distance
**This system passes ' the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volad organic compounds indicates that the well is free from pollution from that facility and
the presence o moma nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure crit a are triggered.A copy of the analysis must be attached to this form.
3. Other:
tt 4
;t
IN."
W
3 i•w
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 126 Old Town Road
Hyannis;MA
Owner: Cheryl Kelly
Date of Inspection: February 5,2003
D. System Failure Criteria Applicable to all systems:
You must indicate "yes"or"no"to each of the following for all inspections:
Cr.}�.-.c., to..�,�v� o.. ✓� S 61.E S-fu:..� ...c.�:.
Yes No
_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent tot a surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
if 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
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.
_,�L 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.
—Az 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 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,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 3I0 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 ad gn flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the crite ' above)
yes no
the system is within 400 feet of a surface drinkin ater supply
the system is within 200 feet of a tributary a surface drinking water supply
1
the system is located in a nitrogen se itive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply 11
If you have answered"yes"to any q tion in Section E the system is considered a significant threat,or answered
"yes"in Section D above the larg ystem has failed.The owner or operator of any large system considered a
significant threat under Sectio or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owners uld contact the appropriate regional office of the Department.
1,ez. .
4
Page 5 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
126 Old Town Road.
Owner: Hyannis,MA
Date of Inspection: Cheryl Kelly
February 5,2003
Check if the followine Dave been done.You must indicate"yes"or"no"as to each of the followinu:
Yes No
✓ _ I'.:;:.i inks information was provided by the owner. occupant.or Board of I i:altl,
_ ✓ Were any of the system components pumped out in the previous two weeks
e� 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?
n1q 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
Welt: all system components,excluding the SAS, located on site ?
_ n�/a Were the septic [aril: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:
Yes no
_AZ 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(3)(b))
�� b
5 n:
f
Page 6 of 1
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
126 Old Town Road
Owner: Hyannis,MA
Date of inspection: Cheryl Kelly
February 5,200jI,LOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design) Al Number of bedrooms(actual):_L
DESIGN flow based on 310'6R 15.203 (for example: 1 10 gpd x#of bedrooms): y41u
Number of current residents: o
Does residence have a garbage grinder(yes or no): yu
Is laundn on a separate sewage system (yes or nu):nw (if yes separate inspection required)
Laundry system inspected(yes or no): /4/-1
Seasonal use: (yes or no): No
Water meter readings, if available(last 2 yearslrsage(gpd)): 0 2
Sump pump(yes or no):
Last date of occupancy: U. p 4, a , o us
COMMERCIAL/INDUSTRIAL
Type of establishment;
Design flow based on
g ( 310 C R 1 M 5.203): -:---gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system (y or no):
Water meter readings, if available: _
Last date of occupancy/use: -
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as pan of the inspection(yes or no): w0
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
_ZOverflow 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)
Tight tank _Attach a copy of the DEP approval
Other(describe):.
Approximate age of all/components. date installed(if known)and source of information:
QY4 Hot � ✓i��K Su ��` t �n .�afQ 3V4"4hS G�Qn
Were sewage odors detected when arriving at the site(yes or no):fro
ri a
T"535 tw��.5 t
x.,:
Page 7 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
126 Old Town Road
Owner: Hyannis,MA
Date of Inspection: Cheryl Kelly
February 5,2003
BUILDING SEWER(locate on site plan)
Depth belo�% grade;: t b"}
Materials of construction: _/cast iron _40 PVC other(explain): (]
Di,tancr fron, pri%atc water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage,etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade:
Material of construction: _concrete_metal___.fiberglass_polyethyle
other(explain)
If tank is metal list age: _ Is age confirmed by a Certificate of Con fiance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or b e:
Scum thickness:
Distance from top of scum to top of outlet tee or aflle:
Distance from bottom of scum to bottom of 9 tlet tee or baffle _
f low were dimensions determined:
Comments(on pumping recommend" ons, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidenc of leakage, etc.):
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal fiberglass_poly ylene_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 t or baffle:
Date of last pumping:.
Comments(on pumping recommendations ' et and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of 1 age,etc.):
C x _
7
�tv
Page 8 of 1 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
126 Old Town Road
Owner: Hyannis,MA
Date of Inspection: Cheryl Kelly
February 5,2003
TIGHT or HOLDING TAk: (tank must be pumped at time of inspec ' n)(locate on site plan)
Depth below grade: --.. _
Material of construction: concrete metal fiberglass olyethylene other(explain):
Dimensions:_
Capacity: gallons
Design Fio�,. __ - gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working orde yes or no):
Date of last pumping:
Comments(condition of alarm and flo switches,etc.):
DISTRIBUTION BOX: (if present must be opened)(locate on ' e plan)
Depth,of liquid level above outlet invert:.
Comments(note if box is level and distribution to outlets a al,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 or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition o umpsand appurtenances,etc.):
4 s ;.
8 = °
Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
126 Old Town Road
Owner: Hyannis,MA
Date of Inspection: Cheryl Kelly
February 5,2003
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits. number:
leaching chambers, number:
leaching galleries,number:
leaching trenches,number, length: _
_leaching fields,number,dimensions:
overflow cesspool,number: ?
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp soil,condition of vegetation,
etc.):
�S'� a v...- lC��_��_ ..�•, � ��.,,q � .. t't, N ti_�� j�✓••.-. S..: �.,( ,v w _S . ' �.. I-'-r- c.,.�.1t
CESSPOOLS: ✓ (cesspool must be pumped as part of inspection)(locate on'site plan)
Number and configuration: DL,t
Depth--top of liquid to inlet invert: —
Depth of solids layer. _ 1
Depth of scum la'er: }
Dimensions of cesspool: Xj— l'
Materials of construction:
Indication of groundwater inflow(yes or no): �!
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
u
S L ✓ b ( A t� w a.S T�•-' ._�_✓�._�`+ w !/3 G- a✓c---= h t
PRIVY: .(locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note.condition of soil,signs of hydraXiie, level of ponding,condition of vegetation,etc.):
5 1 .
9 a;
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 126 Old Town Road
Hyannis,MA
Owner: Cheryl Kelly
Date of Inspection: February 5,2003
SKETCH OF SEWAGE 61SPOSAL SYSTEM
Provide a sketch 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.
I�
3z 3v �
S3�
L„5ir��15.
' Page 11 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:
126 Old Town Road
Owner: Hyannis,MA
Date of Inspection: Cheryl Kelly
February 5,2003
SITE EXAM
Slope
Surface water
Check cellar ✓
Shallow wells
Estimated depth to ground water %5 1'feet Adjusted high ground water elevation —_feel
Please indicate(check)all methods used to determine the high ground %%ater elevatiow
_Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Ilealth-explain: _
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain: M w 2.7 K_Z L
You must describe how you established the high ground water elevation:
.._��2�.'�—•_1 .4 rc<.�___.`�.Y�'-/9 . {1—CaJ=w . �ci f / Z �� _- G
This report has been prepared and the system inspected as of the date of inspection. This report is not a
warranty or guarantee that the system will function properly In the future. There have been no warranties or
guarantees,either expressed,written or implied, relating to the system,the Inspection and/or this report.
11
SYSTEM PROFILE
TOP FNDN• = 39.5 TEST HOLE LOGS
ACCESS COVER TO WITHIN 6" OF FIN. GRADE (NOT TO SCALE)
I = r ACCESS COVER (WATERTIGHT) TO ENGINEER: A.H. OJALAi PE
f 39.0' MINIMUM .75' OF COVER OVER PRECAST WITHIN 6" OF FIN. GRADE SAM WHITEBOH
2% SLOPE REQUIRED OVER SYSTEM WITNESS: _( )
T .. 39.0'
36.7't* FRUN PIPE OR FIRST LEVEL 2" DOUBLE WASHED PEASTONE DATE: - 4/3�03
PERC. RATE - < 2 MIN/INCH
I,"
PROPOSED 1500K �� 0� T i
//" 36.27
GALLON SEPTIC t 36.05, r CLASS I SOILS P#
36.30' TANK (H- 10, ) o
Er"
35.77 cAs eA�e� 000c> 3 .7 ' o SIDESMIN35.95 ® ENDS Q Locus,
( 2 % SLOPE) 2' 0�� ELEV.
� S 1_
� 6" CRUSHED STONE OR fvtECHANICAL
COMPACTION. (15.221 [21) � o TERR.
DEPTH OF FLOW = 4' y, SLOPE) ( 1 5� SLOPE) "`''�8 088 114" r � o��'g 33.77' S
TEE SIZES:
INLET DEPTH = 10" 3/4" TO 1 1/2" DOUBLE XASHEG STONE 8" 1 OYR 3/2 CRAIcwLLE BEACH RD.
OUTLET DEPTH 14"
BW LOCATION MAP NO SCALE
LEACFOUNDATION- 19' SEPTIC TANK 10' D' BOX 3P FACILITY
Y NG LS ASSESSORS MAP 268 PARCEL
ACILI( 82 f
10YR 5/6
4.77' 18.7't 24" 37.0'
*THE INSTALLER SHALL VERIFY THE
LOCATIONS OF ALL UTILITIES AND ALL
BUILDING SEWER OUTLETS AND ELEVATIONS
PRIOR TO INSTALLING ANY PORTION OF
SEPTIC SYSTEM C
MFS
BOTTOM TH EL. 29.0'
GROUNDWAIFR EST. AT EL. 15f PER TOWN GW MAP
2.5Y 6/6 �
DESIGNING ENGINEER CERTIFY INWRITING
INSTALLATION.,AN p IN STRICT
THE SYSTEMTOSPLAN.
120 29.0 ACCORDANC
+ 40.5
NO WATER ENCOUNTERED
+ 37.2
NOTES:
36.4
x x---X >F-39-i-x x x x-----+ 40.8 ' APPROX. NGVD
SEPTIC DESIGN: (GARBAGE DISPOSER IS NOT ALLOWED 1 .: DATUM IS
3 -
89.57' 4 ,n , 2. M._1!��lClPr,i, N!'1TE�i l.� EXISTING
111.0 ' \ / vESIGN F' ^ r!. 11 C _ 40
BEDROOMS n� r
4 3. MINIMUM PIPE PITCH TO BE 1 8" PER FOOT.
USE A _ 40 GPD DESIGN FLOW /
+ 3 16° Plha 4. iE'SIGN LOADING FOR -R I " r r?� AC a 1 a-- �'�
I PTIr` TA NV, hn _ ,� 0 G _O AL1_. PRECAST T_ .)N„TS TO „ l I
16 PINE _ . // _ E Itil, G 2 R (� C., Un I
+ 38.7 <` � + 3
5. PIPE JOINTS TO BE MADE WATERTIGHT
+ 4
USE A 1500 GALLON SEPTIC TANK 6. CONSTRUCTION DETAILS TO BE IN ACCORDANCE WITH MASS.
36.9 8.6 14 8 7 16" TREE LEACHING: ENVIRONMENTAL CODE TITLE V.
;\ SIDES: 2(40.5 + 9.83) 2 (.74) = 149 7.' 7H15 PLAN IS FOR PROPOSED WORK ONLY AND NOT TO BE
I TH I USED FOR LOT LINE STAKING.
37.1 " � BOTTOM: 40.5 x 9.$3 (.74) = 294 8. PIPE FOR SEPTIC SYSTEM TO SCH. 40-4" PVC.
\ � EXIST. DWELL. 16 PINE
TOP FNDN = 39.5' 1 + 39.4 o I t!rjTOTAL: 99_ S.F. 443 - GPD 9. COMPONENTS NOT TO BE BACKFILLED OR CONCEALED WITHOUT
\ 35 16 CHER + 4 USE 6 HIGH CAPACITY INFILTRATORS WITH 3.5' INSPECTION BY BOARD OF HEALTH AND PERMISSION OBTAINED
' BOO 7d + 39.3
+ \ �� G 20" MAP + 38y , FROM BOARD OF HEALTH.
w** _ + 3 STONE AT SIDES, 1.5 AT ENDS AND 14 UNDER
� \ � � 10- CESSPOOLS TO BE PUMPED AND REMOVED.
\ 0 391� 16" PINE I
1 39.s + 40.2 0' LEGEND
Q 37. 3 1 / I
\ 7' L + PROPOSED SPOT ELEVATION
�\ 0RP b` 1 ooxo TITLE 5 SITE PLAN
39.8 40 EXISTING SPOT ELEVATION
\ 16 Ado I
100 °F 126 OLD TOWN ROAD
a ; 180''rf PROPOSED CONTOUR
C \ 3,9 F2APLE
MARK - NAIL SET IN 0 100 EXISTING CONTOUR
IN' THE TOWN OF:
\47.9 ELEVATION 42.4 (WEST HYANNISPORT) BARNSTABLE
38.7 PREPARED FOR: C H E RYL K E LLY
**WATER LINE DRAWN FROM BOARD OF HEALTH
WATER SHUTOFF TO WATER 20 0 20 40 60 Feet
METER (ASSUMED LOCATION; MA
UNMARKED AT TIME OF PERC 40.7 APPROVED DATE
TEST.) CONTRACTOR TO CONFIRM EXIST. DWELL.
1 = 20 APRIL 8, 2003
LOCATION PRIOR TO EXCAVATION. - SCALE: " DATE:
off WS-362-4541
fox 508 362-9880
1
down cape engineering, inc, �/ 0 N Of
ARNE
CIVIL ENGINEERS o H.
0 LA oJAEH.
�„
LAND SURVEYORS -o N 6348 CIV►
939 vain st. yormouth, mo. 02675 isrE '° srEA
i Rim «ts G�� G
03-051 ARNE H.~OJAI.A, L.S. DATE