HomeMy WebLinkAbout0071 PEACOCK DRIVE - Health _ 71 Peacock Drive, Hyannis
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Commonwealth'of Massachusetts
Tithe 5 Official Inspection .Form
Subsurface Sewage Disposal•System Form- Not for Voluntary Assessments
1M 71 Peacock Drive
Property Address
Gordon Bellemer
Owner Owner's Name - y
information is required for every Hyannis MA' 02601 ' 8-26-16 �$ .
page. City/Town State. Zip Code Date of Inspection
Inspection results must be submitted on this form. 1.nspection,forms,may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When fillingout forms A. General Information S/�r f l BgR `����qu4n►ryp���
on the computer; ``����` �,SN OF Al, Niz����` z
use only the tab 1. Inspector:
key to move your O G
cursor-do not James D.Sears __ DAMES
use the return = c'
key. Name of Inspector
Gapewide Enterprisses, LLC
Company � TI�
an Name
tan P Y �1zii
153 Commercial Street ipiuu,►+r+,,,,;�����`
Company Address`'
tenon Mashpee MA 02649
Citylrown 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 reportedbelow 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:
8-26-16
nspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system 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.
15ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 17'
Commonwealth of Massachusetts
W Title 5 Official Inspection[ Form
Subsurface Sewage,Disposal System form Not for Voluntary Assessments
71 Peacock Drive
1y e
Property Address
Gordon Bellemer
Owner Owner's Name
information is required for every Hyannis _ MA 02601 8-26-16
page. Cltylrown. State Zip Code Date of Inspection
B. Certification '(cont.)
Inspection Summary: Check,A,B,C,D or E/always complete all of Section D
A) System Passes:
Z I have not found any information which indicates that any of the failure criteria described . r.
in 310 CMR 15.303'or in 310'CMR 15.304 exist. Any failure criteria not evaluated are
f indicated below.
Comments:
The system is 1000 Gal. Tank DBox and pit. -
B) System Conditionally Passes:
❑ One or more system components.as described in the"Conditional.Pass" section need to be
replaced or repaired: The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
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 br exfiltration or.tank failure is-imminent. System will pass
inspection if the existing tank is-rep laced 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 than20 years old.is•available:
7 ❑ Y ❑ N ❑ ND (.Explain below);
t
ti
t5ins.doc rev.6/16 - - - - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17.
ICommonwealth of Massachusetts
W Title 5 Official -Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 71 Peacock Drive c
Property Address
Gordon Bellemer.
Owner Owner's Name
information is required for every Hyannis r MA ,02601 8-26-16
page. City/Town I State-; Zip Code Date of Inspection
B. Certification (cont.)
El Pump Chamber pumps/alarms not operational..System will pass with Board of Health approval if
Pumps/alarms are repaired.
B) System.Conditionally Passes (cont):
❑ Observation of sewage backup or.break out'or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑'.Y ❑ N ❑ ND (Explain below): ,
distribution box is leveled or replaced ❑ Y ❑.-N ❑ ND (Explain below):
i
❑ 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): -
El broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below) 0.
❑ obstruction,is removed ❑ Y ❑ N ❑ ND (Explain below):
I .
C) Further Evaluationiis Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if' .
the system is failing to protect public health,safety or the environment. .
1. System will pass unless Board of Health determines•in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
' safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a,bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17.
' a
Commonwealth of Massachusetts
W Title 5 Official Inspection :Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
71 Peacock Drive
Property Address
Gordon,Bellemer -
Owner Owner's Name
information is Hyannis MA 02601 8-26-16
required for every H y ,
page.. City/Town State Zip Code Date of Inspection -•
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public,Water Supplier, if any)
determines that the system is.functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the.SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within_a Zone 1 of a public water
supply.
❑ _The system has a septic tank and SAS and the SAS is within 50 feet of a private water'
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at.a DEP certified laboratory, for fecal
' coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to.or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be,attached to this form.
3. Other:
D) System-Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:.
Yes No
ElBackup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in NEEM is less than 6" below invert or available volume is less
than 1/dayflow Pj r '
t5ins.doc•rev.'6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 4 of 17
y
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System,Form - Not for Voluntary Assessments
71 Peacock Drive
Property Address i
Gordon Bellemer l
Owner Owner's Name a
information is required for every Hyannis # MA ' 02601 8-26-16
page. City/TownState Zip Code Date of Inspection
B..Certification (cont.)
Yes No
^ , ®• ,Required pumping more than 4 times 6 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.
❑ z Any portion-of a cesspool or privy is within a Zone 1 of a public.well.
t
f ❑ ® 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.
❑ Z 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.
I. A
Yes No
❑ ❑ the}system is within 400 feet of a surface drinking water supply
❑ ,> ❑ #helsystem 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
•
Q El Area- IWPA) or a mapped Zone Il of a-public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
S
Commonwealth of Massachusetts
W Title 5 ,OfficialrInspectionform.. . ,
Subsurface SewagwDisposal System Form -Not for.Voluntary Assessments-
71 Peacock Drive
Property Address
Gordon Bellemer +
Owner Owner's Name
information is required for every Hyannis i MA_ 02601 8-26-16
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate,"yes" or"no".as to each of the following:
Yes. No
- ® ❑ Pumping information was provided by the owner, occupant, or Board of Health
.t
❑ Were any of the system components pumped out in the previous two weeks?
❑ Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently or as part of
this inspection? ,• , ..
Were`as built plans of the system obtained and examined? (If they were not
0 El
available note as N/A)
® ElWas the facility or dwelling inspected for signs of sewage back up?
0 ❑ 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.
El
IDDetermined 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
i
Residential Flow Conditions: ,
r _
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
,4 330
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
I
t5ins doc•rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form '
Subsurface Sewage Disposal System form - Not for Voluntary Assessments
,M 71 Peacock Drive
Property Address.
Gordon Bellemer
Owner Owner's Name -
information is MA 02601 8-26-16
required for every Hyannis
page. Cityrrown State Zip Code Date of Inspection
D. System Information.
Description:
The system is a 1000 Gal Tank D Box and pit.
1
Number of current residents:
Does residence have a garbage grinder? ❑ Yes 0 No
Is laundry on a separate sewage system? (Include' aundrysystem inspection
information in this report.) ❑: Yes ®: No
Laundry system inspected? El Yes K No
Seasonal use? ❑ Yes ®. No
Water meter readings, if.available last 2 ears usage d °2014-135,000G s
g ( Y 9 (gp )) 2015-345,000GaI's -
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
'.. iJate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203)` Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): -
Grease trap present? - ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title'5 system? : ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 71 Peacock Drive
Property Address
M
Gordon Bellemer
Owner Owner's Name
information is required for every Hyannis MA 02601 8-26-16
page. City/Town, State ', Zip Code. Date of Inspection
D. System Information (cont.)
Last date of occupancy/use:
Date
Other(describe below):
- r
General Information
Pumping Records:
+ Source of information: 8-2016
Was system pumped as part of the inspection? R : ❑'Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System: ,
' ® Septic tank, distribution box, soil absorption system.
- .
Single cesspool
❑ Overflow cesspool
Privy
Shared system (yes orno)(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):
- r
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts .t
W Title 5 Official Inspection Form,
Subsurface Sewage Disposal SystemForm -Not for Voluntary Assessments
° -71 Peacock Drive
7M
Property Address
Gordon'Bellemer
Owner Owner's Name
information is
required for every Hyannis MA_ 0260.1 8-26-16
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:
NA 8 -2016 New D Box..
Were sewage odors detected when arriving at the site? ❑y Yes. ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron 2 40 PVC E other(explain):
Distance from private water supply well or suction line: - feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40 &SCH 20.
Septic Tank(locate on site plan):
10.1
Depth below grade: x,
feet
Material of construction::
Z concrete ❑ metal ❑ fiberglass ❑'polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 Gal. Precast H-10
Sludge depth: 0 ,
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts -
W Title 5 .Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 71 Peacock Drive
Property Address
Gordon Bellemer
Owner Owner's Name
information is Hyannis MA 02601 8-26-16
required for every y '
page. City/Town State . Zip Code Date of Inspection.
D. System Information (cunt.)
Septic Tank.(cont.)
Distance from top of sludge to bottom of outlet tee or baffle ,
30"
0
Scum thickness
Distance from top of scum-to top of outlet tee.or baffle
12„
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? Asbuilt--Tape
x
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank and covers at 10"below grade. Inlet tee, outlet baffle. No sign of
leakage or over loading.
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
I
' Distance from bottom of scum to bottom of outlet tee or baffle-
Date of last pumping: Date
R
t5ins.doc•rev.6/16 Title 5.0fficial Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal'System Form - Not for Voluntary Assessments
^M 71 Peacock Drive
Property Address
Gordon'Bellemer
Owner Owner's Name
information is
required for every Hyannis MA ' 02601 8-26-16
page. City/Town• State Zip Code Date of Inspection ,.
D. System Information (cont.)
Comments(on pumping irecommendations, inlet and outlet tee or baffle condition, structural integrity;
liquid levels as related to outlet invert, evidence of leakage, etc.):
F
i
Tight or Holding Tank(tank must be pumped at time of inspection) (locate-on site plan):
Depth below grade:
Material of construction:
i
❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
i Dimensions:
Capacity: gallons
Design Flow: _
gallons per day
I
I - •
Alarm present: ❑ Yes -❑ No
Alarm level: Alarm in working order: ❑. Yes ❑ No
Date of last pumping: Date
i- - - -
y Comments (condition of alarm,and float switches, etc.): -
E
I
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
It5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M ,•''r 71 Peacock Drive
Property Address `.
Gordon'Bellemer
Owner Owner's Name
information is required for every Hyannis MA 02601 8-26-1$
page. CityfFown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
.r evidence of leakage into or out of box, etc.):
D Box is 16"x16"-18" below grade w/one line out. Box is New 8-2016 w/cover at 6".
L
Pump Chamber(locate.on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*.
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps'or alarms are not in working order,.system is.a conditional-pass.
Soil Absorption System (SAS)(locate on site plan,'excavation not required):
i .
If SAS not located, explain why:
.r
t5ins.doc-ray.:6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
r
7 -
xf
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments
71 Peacock Drive
Property Address
Gordon Bellemer.
Owner Owner's Name
information is required for every Hyannis MA 02601 8-26-16
page. City/Town t, State Zip Code . Date of Inspection.
D. System Information (cont.)
Type:
® leaching pits . number:
❑ leaching chambers number:
El 'leaching galleries number:
El leaching trenches number,.length:'
s
' ❑• leaching fields': number, dimensions:
s ❑ overflow cesspool number:
' ❑ innovative/alternative system
i
Type/name of technology:
� F
l Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil;condition of
vegetation, etc.):
i Leaching is a 1000 Gal. precast pit. Pit and cover at 2' below grade. 18"water in pit. Stain line at
8" above water level.
I
k
a
Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer -
I Depth of scum layer.
Dimensions of cesspool -
Materials of construction.
Indication of groundwater inflow ❑ Yes ❑ No
.5ins.doc-rev.6/16 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
i
Commonwealth of Massachusetts: t
F Title 5 Official Inspection- Form -�
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 71 Peacock Drive
Property Address
Gordon Bellemer
Owner Owner's Name
information is
required for every Hyannis MA 02601 8-26-16 '
page. City/Town, State Zip Code Date of Inspection
D. System Information ,(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): i
Privy (locate on site plan):
j -
Materials of construction *{
Dimensions.
Depth of solids
Comments (note'condition of Soil; signs of hydraulic failure, level of ponding; condition of vegetation
etc.): ; N -
r
j t5ins.doc-rev.6116 j Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 '
EP � }
' Commonwealth of Massachusetts
z'
Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
71 Peacock Drive
Property Address
Gordon Bellemer
Owner Owner's Name
;nformation is
required for every Hyannis MA 02601 8-26-16
gage. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a.view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
' ® .hand-sketch in the area below K
❑ drawing attached separately
Any (�A
13-3
7
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 ,
i-
.0. Commonwealth of Massachusetts
-
Title 5 Official Inspection Form . r =
mr Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,
.N ,. 71 Peacock.Drive
Property Address
Gordon Bellemer
Owner Owner's Name
information is Hyannis MA 02601 8-26-16
' required for every y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (coat.) w
Site.Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar.
❑ Shallow wells
35+
Estimated depth tofl�ig_h ground water: feet
Pleaseindicate 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)
Z Checked with local Board of Health -explain:
Maps on file & Past report
Checked with local excavators, installers- (attach documentation),
Accessed USGS database -explain:,
You must describe how you established the high ground water elevation:
•G W of Barns Maps and Past Report
Before filing this Inspection Report; please see Report Completeness Checklist on next page.
t5ins.doc-rev.6116 .Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
H W Title 5 Official Inspection Form
V Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
71 Peacock Drive
Property Address
Gordon Bellemer
Owner Owner's Name r
information is Hyannis . MA 02601 8-26-16
required for every
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
Z System Information—'Estimated depth to high groundwater,
® Sketch of Sewage Disposal System either drawn on page"15 or attached in separate file
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
T WN OF BARNSTABLE
LOCATION ►e�GQc.�� / SEWAGE#
U .LAGE. lyiytrlls ASSESSOR'S MAP&PARCEL o�G 9
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY /ClUl7
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS 3
OWNER -V Iwk +y
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted GroundwaterTable 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 --1-/1SpeJ,-q6J re1-�
�nl
�C Q
Imo'
C
o� �' lLk
No. •� Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
01pplitation for Disposal 6pstem Construction Permit
Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. '7` �L b P, Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel a(pq /0 - / Vf
Installer's Name,Address,and Tel.No.509-q17—g$'?7 Designer's Name,Address,and Tel.No.
CIAPEwtt>G Lox
/53 co Itf-A&P625
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
i
Nature of Repairs or Alterations(Answer when applicable)
r
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 Certificate of
Compliance has been issued by this Board of Heal
Signed Date
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. Date Issued v�
------------------------------------------- - - - --!
No. l b ''_ '30 ... ..;` . a r Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
�.Zippf catioriirfor`,,�i`sposaY 6pstem Construction Permit
Application for a Permit to Construct( ) Repair(k Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Addressor Lot No. o71 j7�4<!O�Lp_ AP, Owner's Name,Address,and Tel.No. ,
Assessor's Map/Parcel a(pq ct /Q 14ui4�N/s
Installer's Name,Address,and Tel.No.5OQ-477_1?9" 7 Designer's Name,Address,and Tel.No.
CAPEWl t>6 E iQ)S ES U..C.
l53 Go Sz- r-t•4s�PE� N�A ,
Type of Building: ;
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
" Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer whemapplicable) '
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 Certificate of
Compliance has been issued by this Board of Healt
Signed Date S X a l�p
Application Approved by Date
S' !
Application Disapproved by Date
z for the following reasons
Permit No. i {p �6 yc -' Date Issued
---------------------------------------------------------------------------------------------------------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(4) Upgraded( )
Abandoned( )by^MCA Pt w t De ��y�2�/.t K� L La
at ! / E 6�Q�,r` O}Zj U(— H Au IS -has been constructed in accordance
I r
with the provisions of Title 5 and the for Disposal System Construction Permit No.. /& Q dated '
Installer CA PGw(t,� ��PAJ5t✓ UQ Designer MJA
#bedrooms Approved desi allow N gpd
i
The issuance of thij permit shall not be construed as a guarantee that the system will fimct as de 1 ed. C ti
�r \ 3 }Date $ 1, Inspector 9
No. 30 C-;�- ,a Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposar 6pstem Construction hermit
Permission is hereby granted to Construct( ) Repair( � Upgrade( ) Abandon( )
System located at 7 JPEACc)c` DR)VE HY-A M, J(S
and as described in the above Application for Disposal System Construction Permit. The applicant recognized 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 p rmit.
Date a57w b Approved b
AsBuilt Page 1 of 1
T WN OF.BARNSTABLE
LOCATION, t l eAGoc,
Q/ SEWAGE#
VILLAGE, �Y"1S ASSESSOR'S MAP&PARCEL a69
INSTALLERS NAME&PHdNE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS' 3
l
OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the: .
Maximum Adjusted Groundwatei 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 wetrands exist L
within 300 feet of leaching facility) >> Feet
FURNISHED BY gA;K.(!rT,,1 FOtC
A
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30 ra
ay
3 % ao
htt //iss 12/intranet/ ro data/ rebuilt.as x.ma ar=269210&se =l, -� 8/26/2016
P� q P p P P � pP q-
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT-OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM.
PART A
CERTIFICATION
y 9 �16
Property Address: 71 Peacock Drive
W. Hyannisport, MA 02.672
Owner's Name: Peter& Georzia Doherty
Owner's Address: 10 Glad Valley Drive
Billerica, MA 01821
Date of Inspection: March 15, 2007
y
Name of Inspector: (Please Print) Janes M Ford
Company Name:. James: .. Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-00.49.
Telephone Number: (508)862-9400 -
CERTIFICATION STATEMENT
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 systeiri
r'
✓ Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authty
co
y
F it
Inspector's Signature: ' Date: April 4 200
co
The system inspector shall subA a copy of this inspection report to the Approving Authority(Board of ealth or :c
DEP)within 30 days'of completing this inspection. If the.system.is a shared system or has a design.flow. f 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
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/1.5/2000 page 1
}
. j
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'
�. . PART A.
CERTIFICATION (continued)
Property Address: 71 Peacock Drive
West Hvannisport,MA
Owner: Peter&lGeorkia Doherty f
Date of Inspection: March 15. 2007
j
Inspection,Summary: Check A,Ii C,D or E/'ALWAYS complete all of Section.D
A. System Passes: r
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. tAny failure criteria not evaluated are indicated below. .
Comments:
1
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 Iof the replacement or repair;as approved by the Board of Health,'will'pass. "
Answer yes,no or not determined(Y N,ND)in the,-_ 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.bythe Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not jeaking 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 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
obstruction is removed
distribution box is leveled or replaced
ND explain:
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,
obstruction is removed
ND explain:
2
I
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 71 Peacock Drive
West Hvannisport. MA
Owner: Peter&Georgia Doherty
Date of Inspection:. March 15, 2007 `
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. y
L• 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
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system-is functioning in a manner that protects the public health;safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of,a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well**., Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria 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.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 91 Peacock Drive
West Hyannisport, MA
Owner: Peter&Georizia Doherty
Date of Inspection: March 15, 2007
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2 day flow
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.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.]
No (Yes/No)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 System:
To be considered a large system the system must serve.a facility with a design 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 1 systems in addition to the criteria above)
Yes No,
the system is within 400 feet of a surface drinking water supply
the system iswithin 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area=IWPA)or a mapped
Zone II of a public,water supply well
If you have.answered;`yes"to any question in Section E the system is considered.a significant threat,or answered
"yes" in Section D above.the large system lias 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.B
CHECKLIST
Property Address: 71 Peacock Drive:
West L6 annisport, MA
Owner: Peter&Georgia Doherty-
Date of Inspection: March I.S. 2007
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?
J Has the system received normal flows in the previous two week period
✓ Have large volumes-of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out
✓ _ Were all system components,excluding the SAS, located on site?
Were the septic tank manholes uncovered,opened;and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth`of sludge and depth of scum?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the.Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ 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)).
5
Page 6 of 11
OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 71 Peacock Drive
West Hvannispor't. MA
Owner: Peter&Georaia Doherty
Date of Inspection: March 15. 2007
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 - Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15:203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 0
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump-Pump(yes or no): No
Last date of occupancy: Weekend use
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): spd .
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(yes or no):
Water meter readings, if available: `
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Never pumped-per owner
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank, distribution box,'soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system"(yes or no) "(if yes,attach previous inspection.records,if any)
Innovative/Alternative technology. Attach a'copy of the current operation and maintenance"contract(to be
obtained from system owner)
Tight.Tank . Attach a copy"of the DEP approval
Other(describe):
Approximate age of all components,date_ installed(if known)and source of information:
Date of installation unavailable.
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7.of 11
OFFICIAL INSPECTION FORM-NOTFOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued),
Property Address: 71 Peacock Drive
West Hyannisport, MA
Owner: Peter&Georgia Doherty
Date of Inspection: March 15, 2007
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private 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: 12"
Material of construction:: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 Qal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee.or baffle condition,.structural integrity., liquid levels
as related to outlet invert,evidence of leakage,etc.):
n
C
Page 8 of 11
OFFICIAL INSPECTION FORM NOT FOkVOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 Peacock Drive
West Htiannisport, MA
Owner: Peter&Georgia Doherty
Date of Inspection: March 1 S. 2007
TIGHT or.HOLDING TANK: None (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/day.
Alann.present.(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Corn ments(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 D-box was normal with no solids present.
PUM.CHAMBER: None .-(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 of pumps and appurtenances,etc.):
8
i
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 71 Peacock Drive
West Hvannisport, MA
Owner: Peter& Georkia Doherty
Date of Inspection: March 15, 2007
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on_site plan,excavation not required)
If SAS not located explain why:
Type '
✓ leaching pits,number: I-6'x 6'(1000 ag l.)
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length: "
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:. .
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
The leach pit was dry and clean. The scum line was 1.5'up from the bottom. There did not appear to be any signs o£ ailure
The cover was 2'below grade.
CESSPOOLS: None (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 or no);
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: .None (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.):.
r
9
t
' Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE`DISPOSAL SYSTEM INSPECTION.FORM
PART C
SYSTEM INFORMATION.(continued)
Property Address: 71 Peacock Drive °
West Huannisport.MA
Owner: Peter&4GeorQia Doherty
Date of Inspection: March S, 2007
SKETCH OF SEWAGE DISPOSAL 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.
a
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ao c. .
3�
10
• Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C`
SYSTEM INFORMATION(continued)
Property Address: 71"Peacock Drive `
West Hvannisport,MA
Owner: Peter do Georgia Doherty
Date of Inspection: March 15: 2007 .
SITE EXAM
Slope
Surface water -
Check cellar
Shallow wells
Estimated depth to ground water 35+1- feet
Please indicate(check)all methods used to determine the high ground water elevation:
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 Health-explain: Topographic and.water contours imps
Checked with local excavators,installers (attach'documentation)
Accessed USGS database-explain:
You must describe how you established the:high ground.water elevation:
Using Barnstable topographic and water contours Wraps, the traps were showing approxintately 35'.+/-to groundwater at this
site.
This report has been prepared only for"the septic system and components described herein. This septic system has been
inspected and passed 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 septic system, the inspection; this report andlor any components of the septic system which have not
been located and inspected. ;
_' r
,off esr
,.--�
�\ CONINIONAVEALTH OF N ASSACHL'SETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL IRS
DEPARTMENT OF ENVIRONMENTAL P E"P-s
ONE WINTER STREET. BOSTON. NIA 02106 bl'-:S.•!
139
y�or B 9NST
. y�EPTgeCE
V17LLlA�'F WELD ;Q9 -LM CONE
Govcmc Sc:resa.^
ARGEO PALL CELLLYCI DAVID B 5TRL'1-LL
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions
PART A '
CERTIFICATION
Property Address: ? �tL►y,��1t}�ty� S eoQ. Address of Owner: ,\r%" lkwAsv
Date of Inspection: ]C Z3)�°►1 Of different)
Name of Inspector: wC Q 12 I 1 E�cc�o
I am a DEP ap rol ed system inspector pursuant to Section 15.340 of Title S (310 CMR 13.000)
Company Name:f�i a�r-�.'c En as
Mailing Address: 7?p Aovc e_3zf cE H A-9&e" H_ - C�l
Telephone Number: r5e4) /Lrc 2_v
CERTIFICAT10% STATEMF\T )
I certify that I have personall% inspected the se�Aace drsposa! system a: this address and tha, the miormauon reported Belo% is true, accurate
and complete as o;the time of mspen•p" The inspection %A as penormed bases on m% training and experience in the proper iunctror. and
maintenance of on-s-te seAage d,sposa systems TrlsysteT
l
Passes
_ Ccnc-t,ona:;% Passes
_ Neec= Furtne• E%a1ja,.on 9% the Local Appro\.rng AJthorin,
—. Fa_-, '
\19
Inspector's Signature: Date: ,=31`171
E
The Svs:e^ Inspeco' sha" submit a cop% of this inspen.on repor, to the Approving Authoriry within thirty (30! days of completing this
tnspec-or•.. It the srslerr. is a shared system o' ha- a design floes of 10,000 gpd or greater, the inspector and the system owner shall submit
the repo^ to the appropriate regional onice of the'Depar,ment of Eny,ronmm2t Protenron The ongmat should be sent to the system owner
and copes sent to the buve% if applicable, and tne,approving authonn
INSPECT10% SUMMARY: Check A, B, C, Or D
A] SYSTEM PASSES: -
I have not found any information which+indicates that the system violates any of the failure c dtria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are rndrcated belo%. w
COMMENTS. a
B]`SYSTEM'CONDITIONALLY PASSES:
j 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.
indicate yes,no, or not determined (Y. N. or ND'. Describe basis of determination in all instances. If'not determined', explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Cornplrance tanached. indicating that the tank was installed within t- enty 120i years prior to the date of the inspection; or
the septic tank, whether or not me:a!, is cracker, strucwra!!y unscund, shows s�bs•.ar•tial inflltranon orezflltratron, or tank
failure is imminent The system will pass inspection if the existing septic tank is replaced with a conforming septic tank A
as approved by the Board of.Health.
ire,,:a-d 04':5'9-1 face 1 of IC
• • f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner.
Date of Inspection: i
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BI SYSTEM CONDITIONALLY PASSES (continjad
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_ Sewage backup or breakout o•high static water lever observed in the distribut' n box is due to broken or obstructed
pipets) or due to a broken, settled or uneven distribution box. .The system I pass inspection if(with approva! of the
Board of Health;. Describe observations
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due broken or obstructed pipe(s). The system w ill pass
inspection if tw•ith approval of the Board of.Health)
broken pipes; are replaces
oDstruciion is removed
C) FURTHER EVALUATION IS REQUIRED MTHE BOARD OF H LTH:
Conditions exist which reauire further evaluation by th oard of Health in order to determine if the system is fa!Irng to protect the
public health, safes and the environment
1) SYSTEM WILL PASS UNLESS BOARD.OF HEALT DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH A%D SAFETY AND THE ENVIRONMENT:
Cesspool or p,w� is within 50 fee: f a surface water
Cesspoo'• or p•,%-% is within SO f . of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BO D OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT: `
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The systerr has a septic tank',and soil absorption system (SAS) and the SA5 is within 100 feet to a surface water supply or
tributan• to a surface -ater suppy_
_ Tne systern has a se tic tank!and soil absorption system and the SAS is within a Zone I of a public water sup-iv well.
The systeT has a ptic tank,and soil absorption system and the SAS is within 50 feet of a private water supply well
The system has a eptic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
priva!e waver s ply well, u6iess a we!I water analysis for coliform bacteria and volatile organic compounds indicates that
the well is fir from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 p m. Method used to determine distance (approximation not valid).
3) OTHER :
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F A E N'R C SEWAGE _ K
Sl.'BSU E SYSTEM I SPECTIOti F ORH .
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
D) SYSTEM FAILS:
You must indicate h r ' . h t following u dne or the f 1 n e t e -Yes" o o a. to each o e o 0
B
I have determined that the system violates one or more of the following failure cnterr as defined in 310 CMR 15.303 The Dass
for this determination is identified below. The Board of Health should be contacted o determine what will be necessary to correct
the failure
Yes No
Back o{sewage into facility or system comp nent due to an over) r se ded I yD n. Do o c ed SAS or cesspool.
g_ 08€ D�
Discharge or pondrng of effluent to the surface of the ground or s ace waters due to an overloaded or clogged SAS or
cesspool i
Static board lever in the drsrrbutror. bok above outlet invert d e to an overloaded or cloggec 51S or cesspoo'
Lreurd depth rr cesspoo' is lens than 6" below invert or av able volume is iess than 112 day tlov.
Recu,red Dumping more tha',4 times in the last year N due to clogged or obstruaee pipe s
Nurnoer of times,pumped -
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An% Donlon o' the So!' Ansor tron System. cesspool r privy is below the high groundwater eievaSio'.
An% pon:or• of a cesspool or prr--� is wrthrr. 100 f t of a surface water supp!v or tributa-, to a surface water supple
Ant Do-:ron of a cesspoo' or pines is wrthrr` a ne l of a public well.
Ant De-:o- c-a cesspoo' o• pr;r: is.wuh(n 0 feet of a private water supph well A
}
Am po-:,or o:a cesspoo' or prrY\• is less, an 100 feet but greater than 50 feet from a private water supoh• well with no
acceotable. water qua!m ana!sjs�s It me ell has been analyzed to be acceptable, anach coe,, of we!l water analysts for
colriorm. bacer;a -o!at.le organic corn unds, ammonia nitrogen and nitrate nitrogen..
E] LARGE SYSTEM FAILS:
lou must indicate e^ne• `Yes' o• "No" as to each of a following.
The io!;ow:r.g c-rte-,a aop;%,to large syste s in addi�tron to the criteria above.
The system sees a iacrlm with a desrg flow of 10,000 gpd or greater (Large System; and the system is a significant threat to
public health and safeti and the en%iro.ment because one or more of the following conditions exist
Yes No
the system is within 400 eet of a surface drinking water supply
the system is within 2 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 napped Zone II of a
public water supply ell)
The owner or operator of and such s stem shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 00. Please consult the local regional office of the Department for further information.
(revs,see C4 :S '4-
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SL:BSL.'RFACE SE%'AGE DISPOSAL SYSTEM INSPECTION FORM
CHECKLIST
Properi Address: -7l
Owner
Date of nspection: 161�I�
Check if the following have been done You must indicate either`Yes' or 'No'as to each of the following.
%o
Pumping information was provided by the owner,'occupant, or Board of Health.
_ hone of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates. during that period. Large volumes-of water have not been introduced into the system recentl% or
as part of this inspection
As bull, plans have bee^ mna:ned and e-�aTaned: Note if they are not available with WA
The fac:lm or dm.eliln€ .%as inspected for sign!o,sewage back-up
The s%-siem does not receive no'n-sanitary or industrial waste flow.
_ The site %.as inspeaed for signs 9i breakou;.
_ A!l s%ste-r co•npOneni5. excluding the So-! ^osorption System, have been located on the site
• _ The sep:,c tangy nanho;e� were uncovered. opened. and the interior of the septic tank was inspened io, condition of
•• baffles or tees. matena o`cons ruc,ion. dimensions, deptn of liquid,depth of sludge. depth of scum.
The size and loca:,o-, o-*the So-' .Absorption Svstern on the site has been determined based op
_ The iac-ilt% o%%ne• ,anc occupa ts. if d,neren trom ownen were provided with rniormatlon on the proper maintenance o�
Sub-Surface Disposal Svsterr. i
a Exis:,ng mio-rnaoon Ex Ptan a B O H
_ '
L�ece•c,:nec m the i�elc :r any of the failure criteria related to Part C is at issue, approximation of des:ance is
unacce:):at)a 115 302 3;-b ti
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SUBSURFACE SEWAGE DISPOSAL SYSTEM I%SPECTIO% FOR.m
PART C
SYSTEM INFORMA710%
Propern Address: —7( �egGoCi�.
Owner: 1�3t yrJ
Date of Inspection: lol ��''
RESIDENTIAL- FLOW CONDITIONS
Design ilow DSO¢p.d1bedroorr, for S S ,
Number of beerooms
Number o'current residents ®Z -
Garbage g der (yes or no
laundry co--ected to system (yes or no,.
Seasonal use dyes or no•.
%Vater meter readings. if available (last two :2 yea, usage tgx'.m.N-J,
Sump Pump (yes or not
Las: dare o-*occupant, N�
COr►1MERCI,11INDUSTRIAL
Type of es;abltshmen:
Design fto%% _ tahons�aa%
Creme trap present -tees or no `
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Indus:rtat.%%aste Holding Tani; presen; •ves or no
ton-sanita-� wzste d,scna•gec to the 7:;.e 5 syseT i%es or no
%%ater meter reaciings ri avallabie
Las:fa:e o: a
OTHER. De:tribe
Las; cam of occucalc.
CE%ERAL I%FORMATION
PUMPI%G CORDS and source of tnforma:io^
tun�Dec+ 1 Q p �
System pum�pec a. par, of rnspeeoon. Ives or no f�
If yes, vo:ume pumped ¢allons
Reason for pumping
TYPE OF SYSTEM
Septic tank.rdistribution boxsoil absorption system:.
Smg"e cesspool
Ove,flow cesspool
Shared system (yes or no). (if yes, attach previous inspection records, if any)
VA 7echnologv etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date rn'stalled (if known(and source of information: * Ijsj Ij FSS
Sewage odors detected when arriving at the site. iyes or not��
SLBSURFACE SE"ACE DISPOSAL SYSTEM INSPECTIO% FORA
PART C
SYSTEM INFORMATION (continued)
Propertt Address: E PnC'Cr'1L E
Owner: Ito
Date of Inspection: ��Z31 11
BUILDING SEWER: 1
(locate on site plant
Depth below grade.
Material of construction. _cast iron_40 PVC_other.(explains
Distance from private water supply well or suction Ire
Diameter
Comments: (condition of joints, venting, evidence of leakage. etc!
t a
SEPTIC TANK: ]
(locate on site plan
Depth beloN grade #Irj
Material of constructlo .Iconcre:e _meta _F,oe•glas� Pohtthylene othertexpla-n
If tank is meta:. Its: age _ Is age confamec o% Ce^•itca:e o-Compliance 0es.-No
Dimensions �VIJV"1
Sludge depth ;
Distance from top o-. s!udee to bono-+ o-'outie tee o•ba=•e
Scum thickness .
Distance from top of scurr. to top o`outlet tee or ba=a
Distance iro-n boson*: o; scu-n to bo-e-: o'ouil : tee c• ba-.e _
Now dimensions Nere dete•minec
Comments
trecommendation ter pumping tondit.on o; in;e• arc o.,tie! tees or bathes: depth of liquid level m reia ion too tlet invert, u[tural
integrin, e�idence of leas. , e:c i r
GREASE TRAP:
(locate on site plan;
1 `
Depth below grade ;
Material of construction. _concrete _metal!—Fiberglass _Polyethylene - other(explain)
Dimensions: r
Scum thickness: `
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bortom of outlet tee or bafite
Date of last pumping
Comments: `
(recommendation for pumping, condition of isilet and outlet tees o!baffles, depth of liquid level in relation to outlet invert, structural
integrity. evidence of leakage. etc :
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SLISSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR..M
PART C
SYSTEM INFORMATION (continuedi
Prope Address: 7( ( ,
OM nerr:N � ,�
1 I p.1
Date of Inspection:
16
tz3b7
TIGHT OR HOLDING TA%K: ?ank must be pumped prior to, or at time. of mspectioni
(locate on site plan,
Depth below grade
Material of construction _concrete _metal Fibergiass _Polyethylene —other(explain)
Dimensions.
Capacity gallons
Deslg^ floN s
gal,or's da.
Alarm level A:a•r-N in %.pricing o•de• _ Yes _ no
Date of previous punlp'ng
Comments
(condition of inlet tee cond.ttor. o• a!a,rr. and float sAitches. etc.t
a
DISTRIBUTION BOa:
oocxe on sae p a-
De.:^ c`. licu!c le,e' aoo.e outle: jn%e' OuUrjrLb�
ae le e' anc d's:•1t- e u e< ce+ce e s !yes rno�er. �dence of leakagy,�n;'`rout of boa, etc.t
PUMP CHAMBER:—NN)
(locate on site plan
Pumps in working order. (Yes or No,_,
Alarms in working order Res or No
Comments.
mote condition of pump chamber, condition of pumps and appurtenances,etc.)
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Proper IN Address:1 t P�r/tr
Owner: �1 10 Hl/
Date of Inspeclion:16 � _
SOIL ABSORPTION SYSTEM (SAS):
(locate on site.plan. if possible, exca% -on not required, but may be approximated by non-intrusive methods,
if not determined to be present, explain
Tape
leaching pits. number.Lfp
leaching chambers, number._
leaching galleries, number.
leaching trenches. numbe,,(ength
leaching fieids, numbe•, ci,-+ens,o
ove:io, cesspool, nurrmbe-
Aherna:ive-sysierr
Name of Tecnr.oiog%
Comments
t0 corlditionpp so-i s•g^s o" h •-ajvc fa-djr le,. '.of rid condo Or, f ve etation, e�t t�
( - g
CESSPOOLS:
(locate on site pear
Numbe, and co-!*'g.,•a',or. f
Depth-top of ho,,id to inlet Inver,
Depth of solids lave-
Depth of scum lave
Dimensions of cesspoo:
Materials of construao^
Indication of groundNa:e•,
inflow tcesspool m.,s: De pumpez as par, of inspectjon.
Comments.
Incite condition of soil, signs of hydraulic failure, level of ponding. condition of vegetation; etc.)
PRIVY:_
(locate on site plant
Materials of construction: Dimensions.
Depth of solids. _ y
Comments
(note condition of soil, signs of hydraulic failure.. level of ponding, conduion of vegetation. tic)
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SI,BSURfACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATIO.%-
(continued
t
Propemh Address:
Owner:
Date of Inspectlon:'���Q� '
11 i
SKETCH OF SEWAGE DISPOSAL SYSTEM: '
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 (Locate where public water supply comes into house)
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34
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM'
PART C
SYSTEM INFORMATION (continued)
Propert% Address:
Owner:
Date of I spedlonNlO1Z3�c�
Depth to Ground%ate•t.ZO'fee:
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained irorn Design Plans on record
Observation o;Site (Abining property, obsenaiion hole, basement sump etc.)
Determine.it from local conditions
Cnec: %+an loco Scud o' '1Ea':'
Chec. FEMA to.acs
Cnect. pimping records
Cnecl loca' e.ca:a:o•s irs:a•le•s
Lse .5:5 D a.j
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Describe in %o,• �,�- „o•c: r,•,. %c_ esan:-0)ec me el G'OundAxer Elevation. (Must be completed
Grs•���t�� �a�lcu� ��Cy�naraycc �v��>��� JJ N•A f�tZ 31
LOCATION ; , SEWAGE PERMIT NO.
VILLAGE ,
n n
INSTALLER'S NAME f� ADDRESS
e 8 U I L D E R OR OWNER -
�
� Q 1d �i• � -t�i �i✓.� `
DATE PERMIT ISSUED 1 �.
ODATE COMPLIANCE ISSUED . ,�j3
._ � _ �
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