HomeMy WebLinkAbout0008 PARK PLACE - Health 8 Park Place
Hyannis r
#° A=286-017
f
n
T
;t
e
c
T �I
I
TOWN OF BARNSTABLE
LOCATION G r Pik w- SEWAGE#
VILLAGE ; ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
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
Edges of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY �'
MA 02647 9 a30-12
state Zip Code ... Date of Inspection
m,'Information (Cont.)
''Sewage Disposal System:Provide a view of the sewage disposal system,idludi
two permanent reference landmarks or benctimarks.Locate all wells within 100 fee
ublic water supply enters the building.Check one of the boxes below:
d-sketch in the area below
g attached separately
PARK P�A�E
FS' WIVE
r,,4}�
c
/ a Z.23'
12.1 G`
r
Commonwealth of Massachusetts 1698&--ol 7-
Title 5 Official Inspection, Form
Subsurface Sewage Disposal System,Form-Not for Voluntary Assessments::
rfl
8 Park Place
Property Address
Bishop '
Owner Owner's Name '
information is �.
required for Hyannisport ✓ MA 02647 11/7/18
every page. City/Town State Zip Code Date:of Inspection
Inspection results must be submitted on this form. Inspection forms may noit be altered in any
way. Please see completeness checklist at the end of the form.
r
A. Inspector Information S1r/849�f
Frank Nunes III
Name of Inspector
saa
Company Name
Box 841
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508.272.6433 113010
Telephone,Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 16.340 of Title
5(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
Ar
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails '
t
11/7/18
Inspectof%-Sign9tu4 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 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 form should be sent to the systemmowner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
f
Commonwealth of Massachusetts
- Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
8 Park Place
Property Address
Owner Bishop _
information is Owner's Name
required for Hyannisport MA 02647 11/7/18
every page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the faildre criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
iti 2) System Conditionally y Passes: .
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by `
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank'is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if-it is structurally sound,-not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N, ❑ NDy(Explain below):
}
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 8 Park Place
Property Address
Owner Bishop
information is Owner's Name
required for Hyannisport MA 02647 11/7/18
every page. Cityrrown State .Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ 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 E 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 pipes)are replaced. ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required bythe 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.
a. 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:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
�n F Title 5 Official Inspection' Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Park Place
Property Address
Owner Bishop
information is Owner's Name
required for Hyannisport MA 02647 11/7/18
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cone.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet Hof a bordering vegetated wetland or a salt marsh
b. 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. 4
❑ 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.
c. Other:
4) 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
V 8 Park Place
Property Address
Owner Bishop
information is Owner's Name
required for Hyannisport . MA 02647 11/7/18
every page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
El ® 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CM 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.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,600 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 CA.
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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts .
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Park Place
Property Address
Owner Bishop
information is Owner's Name
required for Hyannisport MA 02647 11/7/18
every page. Cityrrown State Zip Code Date of Inspection
C. Inspection. Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304, The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes"or"no"for each of the-following for all inspections:
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 gnormal flows in the previous two week period?
El ® 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 breakout?
• ❑ 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?
. z
® ❑ 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.
El ® 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)]
t5insp.goc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
8 Park Place
Property Address
Owner Bishop
information is Owner's Name
required for Hyannisport MA 02647 11/7/18
every page. Citylrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): n/a Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
Description:
No design records at BOH
Number of current residents` 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to ,
Is laundry on a separate sewage system? (Include laundry.system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No,
Seasonal use? ® Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
f Last date of occupancy: Seasonal
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Park Place
Property Address
Owner Bishop s
information is Owner's Name
required for Hyannisport MA 02647 11/7/18
every page. Cityrrown State { Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:.
Type of Establishment:
Design flow(based on 310 CMR 15.203): t;auons per day(gpd)
Basis of design flow(seats/persons/sq.ft.;etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: No recent pumping per owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,.volume pumped: gallons
How was quantity pumped determined?,
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
cam, Commonwealth of Massachusetts
�m ro Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
8 Park Place
Property Address
Bishop
Owner information is Owner's Name
required for Hyannisport MA 02647 1117/18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont:)
4. 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):
Cesspool to overflow
Approximate age of all components, date installed (if known)and source of information:
1961 per age of the home
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site.plan):
Depth below grade: 4
-.feet
Material of construction:
® cast iron ❑40 PVC ❑ other(explain):.
Distance from private water supply well or suction line: >10'
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc-rev.7/26/2018 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
�v Title 5 Official Inspection 'Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
0 8 Park Place
Property Address °
Owner Bishop
information is Owner's Name
required for Hyannisport IMA 02647 11/7/18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan): r
Depth below grade: n/a
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a.Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How 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.):
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Park Place
Property Address
Owner Bishop
information is Owner's Name
required for Hyannisport MA 02647 11/7/18
every page. Cityrrown State, Zip Code Date of Inspection
D. System Information (cont.)
7. 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
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
8. 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
8 Park Place
Property Address
Owner Bishop -
information is Owner's Name
required for Hyannisport MA 02647 11/7/18
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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.)'
t II
Attach copy,of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert .
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any, ,
evidence of leakage into or out of box, etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
8 Park Place
Property Address
Owner Bishop
information is Owner's Name
required for Hyannisport MA 02647 1117/18
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.),'
10. Pump Chamber(locate on site plan):
Pumps in working order: 2, ❑ 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.
11. 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:
r. ❑ leaching fields number, dimensions:
® overflow cesspool number: 1
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 113 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
8 Park Place
Property Address
Owner Bishop
information is Owner's Name
required for Hyannisport MA 02647 11/7/18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) A
11. Soil Absorption System (SAS) (cont.),.
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Overflow cesspool is damp at this time,it is approximately 6x6 and of block construction, 32"cover to
12"of grade, no indication of past hydraulic failure,.use caution when excavating there are irrigation
lines that run over the cover
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration cesspool to overflow
Depth—top of liquid to inlet invert 2
12„
Depth of solids layer
Depth of scum layer
3"
Dimensions-of cesspool 6x6
Materials of construction block
Indication of groundwater inflow ❑ Yes ® No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
No indication of past hydraulic failure,•18"cover to 12"of grade, use caution when excavating there
are irrigation lines that run across the edge of the cover, no inlet or outlet T
t5insp.doc-rev.V2612018 Tile 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
c Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Park Place
Property Address
Owner Bishop
formation is Owner's Name
required for Hyannisport MA 02647 11/7/18
every page. CityrFown State. Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
{
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Park Place
Property Address
O Bishop
Owner
information is Owner's Name
required for Hyannisport MA 02647 t 11/7/18
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to,at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
L
p
a� LA(0
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
• Commonwealth of Massachusetts
IF Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forme Not for Voluntary Assessments
8 Park Place
Property Address
Owner Bishop
information is Owner's Name
required for Hyannisport MA., 02647 11/7/18
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water,
❑ Check cellar
❑ Shallow wells
Estimated depth to high'ground water: >15`
feet
Please indicate all methods used to.determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: n/a '
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health explain:
Previous inspection report
❑ Checked with local excavators,,installers-(attach documentation)
® Accessed USGS database-explain..
TOPO mapping, site is 26'rrisl and nearby surface water is 2'msl
You must describe how you established the high ground water elevation:
See above
Before filing,this'inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments
8 Park Place
Property Address
Owner Bishop
information is Owner's Name
required for Hyannisport MA -- 02647 11/7/18
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1,'2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached .
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached -
For 15: Explanation of estimated depth to high groundwater included
,
f
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
aA
Town of Barnstable Building
, � ��z: ..,e.-..._....� -».�,•--�---- -^mow
ve Posted UntilrFinal Ins tect o iZ is n Hale FromMadetreet-Approved Plans Must be Retained on Job and this Card Must be Ket raup� Permit
�W�er
eaa Certi I e o'f Oc u anc is Re uired,such Buildmy shall Not be Occupied l p y q nal Inspection has be -�.��^� �
Permit No. B-2013-04506 Applicant Name: CHARLES R CROVO Approvals
Date Issued: 07/17/2013 Current Use: 1010 Structure
Permit Type: Addition/Alteration-Residential Expiration Date: 01/14/2014 Foundation:
Location: 8 PARK PLACE, HYANNIS Map/Lot: 286-017 Zoning District: RF-1 Sheathing:
Owner on Record: ANDERSON, DOROTHY M TR 1. Contractor,'Name:� CHARLES R CROVO Framing: 1
Address: PO BOX 583 i`. ,' : Cont ractor5License:;,071165 2
x F S :n
HYANNIS PORT , MA 02647 Est.;Project Cost: $360,000.00 Chimney:
Description: REBUILD GARAGE AND FINISH SPACE ABOVE(BEDR)GAR DAMAGED ' Permit Fee: $ 1 886.00
BY FIRE.ABOVE GARAGE CONST 1 BED, 1.5 BATH
� �
81 SIT Insulation:
Paid`.f $ 1,886.00
AREA,SMOKES Final:
Date: 7/17/2013
Project Review Req: aR
Plumbing/Gas
h a tA Building Official
' � Rough Plumbing:
x IL
r -. etc
w Final_Plumbing:
��. � Rough Gas:
a
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance. Final Gas:
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
y.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by laws and codes.
,�--..-�,.�-- � � Electrical
This permit shall be displayed in a location clearly visible from access street orroad and shall be maintained open for public inspection for the entire duration of the
Service:
work until the completion of the same. s
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided-on this permit. Rough:
Minimum of Five Call Inspections Required for All Construction Work:k,_:_ _ ` d
1.Foundation or Footing final'
2.Sheathing Inspection
3.All Fireplaces must be inspected at the throat level before firest flue lining is installed Low Voltage Rough:
4.Wiring&Plumbing inspections to be completed prior to Frame Inspection
5.Prior to Covering Structural Members(Frame Inspection) Low Voltage Final:
6.Insulation
7.Final Inspection before Occupancy Health
Final:
Where applicable,separate permits are required for Electrical,Plumbing,and Mechanical Installations.
Work shall not proceed until the Inspector has approved the various stages of construction. Fire Department
"Persons contracting with unregistered contractors do not have access to the guaranty fund" (as set forth in MGLc.142A). Final:
11/16/2018 AsBu i It
TOWN OF BARNSTABLE
LOCATION r t,2 SEWAGE#
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLER'S AME&PHONE NO +� - O I
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
. 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
Ed g of Wetland and Leaching Facility(If any wetlands exist within
00 feet of leaching facility) Feet
FURIgI M
BY
MA 02647 �03012
_ scale Zlp code
_ - •.: Rafe of trapedie
-m4nformation(cant)
Sewage Disposal System:Provfde a view of the sewage disposal wistatn,In
two PaUmm ntrefefence landmarks or benchmarks.Locate a0 wells WtW icafee
iubfc water supply enters the building.Check one of the boxes detow
id-staahcf fn the area below
wtng attached separately
('�ittlC p.tAct
PY4
R,2=023'
B`/
O - _
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=286017&seq=1 1/2
11/16/2018 AsBuilt
LhttPl/ii,sql2/intranet/propdata/prebuilt.aspx?mappar=286017&seq=1 2/2
't L
^ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
G
8 Park Place
Property Address
Gregg Anderson _
Owner Owner's Name
information is requited for every Hyannisport MA 02647 10-30-12
page. Citylrown State Zp 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 autforms A. General Information
````�rUUlrrtrr,
on the computer. /p `\���` �-SiA�....
AN
use only the tab 1. Inspector
I- 2 ti
key to move your JAM ES G
cursor-do not
J
ames D. Sears
use the return SEALS is
Name of Inspector
key. Capewide Enterprises, LLC
„a Company Name y TF `G `�
153 Commercial Street 'n'' an,Hot u�r"`'��n
Company Address
Mashpee MA 02649
City/Town state Zip Code
508-477-8877 S1623
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.
11-1-12
Glnspectors 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.
Y r` ✓ 1/� I
t5ina•11110 TiUe 5 Official Inspection euriaoe Sewage Disposal S m•P.W 1 of 17
Nov 01 1�07:55p p.2
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a 8 Park Place
Property Address
Gregg Anderson
Owner Ownees Name
information is
required for every Hyannisport MA 02647 10-30-12
page. CityrTown state Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E I always complete all of Section D
A) System Passes:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The system is two block cesspool's
B) System Conditionally Passes:
El 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. NO)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 structuraRy
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
Q Y ❑ N ❑ NO (Explain below):
15ms-11/10 TiVe'50fRoal Inspedian Form:Subsurface Sewage Disposal System-Page 2 of 17
�k
Al
Nov 01 12,07:56p p,3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
B Park Place
Property Address
Gregg Anderson
Owner Owners Name
information is l{ a nnis ort
required for every _Y R MA 02647 10-30-12
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cunt.)
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 or 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
f5irs• It o - TWO 5 Official inspection Forth:Subsurface Sewage Disposal System.Page 3 of 17
Nov 01 12 07:56p p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
8 Park Place
Property Address
Gregg Anderson
Owner Owner's Name
information is
required for every Flyannisport MA 02647 10-30-12
page. Gityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall 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
A/19 ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins-11110 Tile 5 Official Inspection Form:Subaurfacs Sewage Disposal System-Page 4 ar 17
Nov 01 14 07:56p p.5
Commonwealth of Massachusetts
L Title 5 OfficialInspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
8 Park Place
Property address
Gregg Anderson
Owner Owner's Name
information is
required for every Hyannisport MA 02647 10-30-12
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
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 11 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.
tSns-11l10 Ti Ia 6 Offldat Fans:S.k—f— a 01.Saweg poser SYaeem-Paee 5 of 17
Nov 01 12 07:57p p.6
Commo
nwealth of Massachu
setts
Title 5 Official Inspection Form
SubsurFace Sewage Disposal System Form-Not for Voluntary Assessments
8 Park Place
Property Address
Gregg Anderson
Owner Owner's Name -
information is required
Hyannisport MA 02647 10-30-12
required for every
page. CitylTown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done_ You must indicate"yes"or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently cr as part of
this inspection?
N� ❑ ❑ Were as built plans of the system obtained and examined? (If they were not
available note as NIA)
❑ Was the facility or dwelling inspected for signs of sewage back up?
Z ❑ 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): NA Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins•11110 7BIe 5 official Impeclion ran:Subsurface Sewage Disposal Syslem•Page 6 of 17
Nov 01 12-.07:57p p.7
Commonweafth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
8 Park Place
Property Address
Gregg Anderson_ _
Owner Owner's Name
intormation is H annis ort
required for every p MA 02647 10-30-12
page. City/Town State Zip Code Date of Inspection
D. System Information,
Description:
The system is two old block cesspool's
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): NA
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NA
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.fL, 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•11110 Title 5 OKGeI Inspection Forth;Subsurface Sewage Disposal System•Page 7 of 17
Nov 01 12.07:57p p.8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 Park Place
Property Address
Gregg Anderson
Owner Owner's Name
information is required for every Hyannisport MA 02647 10-30-12.
page. City/rown state Zip Code Date of Inspection
D. System Information (cunt.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
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
® cesspool
Overflow cesspool
D Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
Q 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 1/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
(Sins-11r10 Title 5 official Inspealon Form:SuLsurfacs Sewage Disposal System-Page 8 of 17
Nov 01 1 2 07:58p p.9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
" Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
8 Park Place
Property Address
Gregg Anderson
Owner Owner's Name
information is
required for every Hyannisport MA 02647 10-30-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information'(cont.)
Approximate age of all components, date installed(if known)and source of Information:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 4' -----
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_):
Pipeing is cast iron and orange burge
Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
Sludge depth:
t5inG•14/10 Title 5 01cial Insped.an Fom Subsurface Sewage Disposal System-Page 9 of 17
Nov 01 12,07:58p p.10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
8 Park Place
Property Address
Gregg Anderson
Owner Owner's Name
information is H annlS Ort
required for every y P MA 02647 10-30-12
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
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How 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.):
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
ISM•1111C The 6 official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Nov 01 12 07:58p p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
8 Park Place
Property Address
Gregg Anderson
Owner owners Name
information is required for every Hyannisport MA 02647 10-30-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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-11110 Ti9a 5 Oftal Inspection Fonre Subsurface Sewage Disposal System•Page 11 of 17
Nov 01 12 07:59p p.12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
kt�w Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Park Place
Property Address
Gregg Anderson
Owner Owner's Name
information is required for every Hyannisport MA 02647 10-30-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(i#present must be opened) (locate on site plan):
Depth of liquid level above outlet invert ---- - - --
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins -1110 T11e 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Nov 01 12 07:59p p.13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Park Place
Property Address
Gregg Anderson
Owner Owners Name
information is
required for every Hyannisport MA 02647 10-30-12
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching.fields number,dimensions:
® overflow cesspool number: 1
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.)--
Leaching is one 7'-6" block cpool at 39"below grade w/cover at 10". Pool Has 20"water w
/stain line at 30" NO sign of over loading or Hi her stain line
MA/AI
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):.
Number and configuration 1
Depth —top of liquid to inlet invert
8"
Depth of solids layer 4"
Depth of scum layer
Dimensions of cesspool T6
11
Materials of construction Block
Indication of groundwater inflow ❑ Yes ® No
t5ins•11110 Title 5 Official Inspection Form:Subsurfacs Se cage clWasel System•Page 113 of 17
Nov 01 12 07:59p p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
"s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Park Place
Property Address
Gregg Anderson
Owner Owners Name
information is
required for every H annisport MA 02647 10-30-12
page. CltyTTown Stale 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.):
Main PPool T-6"block at 38" Below Grade w/cover at 10"water level at out let line
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_):
k
t5ins-1 If.0 Title 5 Official irspection Fonn:Subsurface Sewage Diiapasal System•Page 14 or 17
Nov 01 12 08:00p p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
8 Park Place
Property Address
Gregg Anderson
Owner Owner's Name
information is
required for every Hyannisport MA 02647 10-30-12
page. Citylrown State Zip Code Date of Inspedion
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
PAR K P.4 L
I 4£ v1L
w a Y
1
A 8 4 33=8y
i
o °
t5ins•11110 Title 5 Official Impedion Form:Subsurface Sewage Disposal System-Page 15 0117
Nov 01 12..08:00p p.16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Park Place
Property Address
Gregg Anderson
Owner Owner's Name
information is
required for every Hyannisport MA 02647 10-30-12
page- City/Town state Zip code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
0
Estimated depth to igh ground water 14+..
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Lot High, Auger, hole at 14' No G.W. Bottom of overflow at 10' Auge Hole4' Below bottom of pool
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
(Sins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Nov 01 1 z08:00p p.17
y
.Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
8 Park Place
Property Address
Gregg Anderson
Owner Owner's Name
information
required for every HY annisport MA 02647 10-30-12
_
Page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Z Inspection Summary:A, B, C, D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
LOC TIA ON Ar L2 SEWAGE# ` �
VILLAGE ASSESSOR'S MAP&PARCEL
INSTALLER'S NAME&PHONE NO � ' O
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO,OF BEDROOMS
OWNEk
PERMIT DATE: COMPLIANCE DATE:
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
Edg of Wetland and Leaching Facility(If any wetlands exist within
00 feet of leaching facility) Feet
FURNI BY
MA 02647 1�30-12
SGfe T.rp Cade Date of Irspedio
Im nformation (cons.)
ASewage Disposal System:Provide a view of the sewage disposal syshem I3Nud
two permanent reference landmarksvr benchmarks.Locate all,welts wftn loo fee
jublic crater supply enters the building.Check one of the boxes below:
id-sketch in the area below
wing attached separately
-,AR K P.t R e E
A 8 �q- =33-'8#
n
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=286017&seq=1 5/24/2013
AsBuilt Page 1 of 1
TOWN OF BARNSTABL "^
3—C a tLrtl�f rt
LOCATION r SEWAGE#
VILLAGE I ASSESSOR'S MAP&PARCEL
INSTALLER'S AME&PHONE NO
SEPTIC TANK CAPACITY
LEACTUNG FACILITY,(type) (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
�.. Maximus Adjusted Groundwater Table to the Bottom of Leaching Facility + Peet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) Feet
Edg�,,ifWetland and Leaching Facility(If any wetlands exist within
feet of leachirg facility) Feet
FUI BY
MA -- LMS47-:. 1"0-12
sufla ZIP Cade •..note at lraaedto
tin nformation(cant.)
XSewage D sposW System:Provide a view of the sewage dlspasai,ysis•rt�,InA•!ud
two per—sent refenwce landmarksa benchmarks,Locate ail wells within 10e.Fee
iublIc water supply enters the building.Check one of the boxes below;
id-sketch in the area below
wing attached separately
PARK! p,4Act
-7
DRIuf
C
A 8 Aa=33�8�
A-Zc.T3'
O
t
1
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=286017&seq=l 11/7/2018