HomeMy WebLinkAbout0587 PITCHER'S WAY - Health (2) 587.,Pitcher's Way
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Nov 10 2015 23:51 Jim The Inspector Man 5085349919 page 19
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Commonwealth of Massachusetts a�70
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
587 Pitches Way ry.a
Property Address
Jennifer Brady Q1
Owner Owner's Name /
information is �/
required for Hyannis MA 02601 11-9-15
page. City/Town State Zip Code Dale 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 A. General Information
filling out forms / 1/�7� ``\ '
on the computer, ` �UNnI�F
use only the tab 1. Inspector-: # .`°��y����H MAy�;'��I
key to move your
cursor-do not 3 �G
use the return James D.Sears _��: JAMES m
ke Name of Inspector =o• SEARS
Y =u
Ca ewide Enterprises,LLC !a
ITV Company Name �1-; RT—iP���O�`
153 Commercial Street INSPE�'����``
Company Address — .,
Mashpee MA 02649
Cdyrrown 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
11-10-15
pector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at.that time.This Inspection does not address how the system will perform in the future under
the same or different conditions of use.
15ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sy9 e�1 of 17
r
Nov 10 . 2015 23:51 Jim The Inspector Man 5085349919 page 20
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r 587 Pitches Way
Property Address
Jennifer Brady
Owner Owners Name
information is required for every Hyannis MA 02601 11-9-15
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E I always complete all of Sectlon 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 a 1000 Gal.Tank D Box and ten high cap infiltrators.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement.or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no' or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old'or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than.20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
15ins-3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Pape 2 of 17
Nov 10 2015 23:51 Jim The Inspector Man 5085349919 page 21
Commonwealth of Massachusetts
RoMp Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 587 Pitches Way
Property Address
Jennifer Brady
Owner Owner's Name
information is required for every Hyannis MA 02601 11-9-15 page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or.break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):.
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe($). 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
13.303(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•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal System.Page 3 of 17
Nov 10 2015 23:51 Jim The Inspector Man 5085349919 page 22
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
587 Pitches Way
Property Address
Jennifer Brady
Owner Owner's Name
Information is required for every Hyannis MA 02601 11-9-15
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
10D 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
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 eeoppo*is less than 6" below invert or available volume is less
than %day flow C111 ti
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Nov 10 2015 23:52 Jim The Inspector Man 5085349919 page 23
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
r�
587 Pitches Way
Property Address
Jennifer Brady
Owner Owners Name
information is required for every Hyannis MA 02601 11-9-15,
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation,
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet'
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A.copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes'or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area —IWPA) or a mapped Zone II of a public water supply well
if you have answered"yes'to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Tills 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Nov 10 2015 23:52 Jim The Inspector Man 5085349919 page 24
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wa 587 Pitches Way
Property Address
Jennifer Brady
Owner information is Owners Name
required for every Hyannis MA 02601 11-9-15
page. CityrTown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened,and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design); 2
3 Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
15ins•M3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 17
Nov 10 2015 23:52 Jim The Inspector Man 5085349919 page 25
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
587 Pitches Way
UV . -
Property Address —
Jennifer Brady
Owner Owners Name
information is
required for every Hyannis MA 02601 11-9-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The system isn a 1000 Gal. Tank D Box and ten high cap infiltrators
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): na
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gaiions 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:
isms•3113 Title 5 Official Inspection Form:SubsuAace Sewage Disposal System•Page 7 of 17
fNov 10 2015 23:52 Jim The Inspector Man 5085349919 page 26
2, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
587 Pitches Way
Property Address
Jennifer Brady
Owner Owner's Name
information is Hyannis MA 02601 11-9-15
required for every �
page. Cllyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: 2013
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
-inspection of the I/A system by system operator under contract.
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins 3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 17
Nov 10 2015 23:52 Jim The Inspector Man 5085349919 page 27
�tx Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
587 Pitches Way
Property Address
Jennifer Brady
Owner Owner's Name
information is required for every Hyannis annis MA 02601 11-9-15
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:
1977- 103 Tank/2010 - D Box&Leaching -2010 -204.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 26"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 4" PVC SCH-40.
Septic Tank (locate on site plan):
Depth below grad 16"e: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 Gal.Precast H-10
Sludge depth:
2"
15ins-30 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Nov 10 2015 23:52 Jim The Inspector Man 5085349919 page 28
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
587 Pitches Way
Property Address
Jennifer Brady
Owner Owners Name
information is
required for every Hyannis MA 02601 11-9-15
page. CityfTowrl State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle 811
Distance from bottom of scum to bottom of outlet tee or baffle 1611
How were dimensions determined? Asbuilt-Tape -Plan
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 cover's at 16" below grade. Inlet baffle, outlet tee. 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
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
f -
Nov 10 2015 23:53 Jim The Inspector Man 5085349919 page 29
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
587 Pitches Way
Property Address
Jennifer Brady
Owner Owner's Name
Information Is required for every Hy
annis MA 02601 11-9-15
-
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order. ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
15ins•3/13 Title 5 Official Inspection Form Subsurface Sewage Disposal Systam•Paga 11 of 17
Nov 10 2015 23:53 Jim The Inspector Man 5085349919 page 30
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M y 587 Pitches Way
Property Address
Jennifer Brady
Owner Owners Name
information is required for every Hyannis MA 02601 11-9-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x 16"-2' Below grade w/two lines out. Box is clean and solid. No,sign of over loading or
solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
15ins•3113 Tille 5 Official Insaecton Form:Subsurface,Sewage Disposal System•Pape 12 of 17
Nov 10 2015 23:53 Jim The Inspector Man 5085349915 page 31
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
587 Pitches Way
Property Address
Jennifer Brady
Owner Owners Name
information is required for every Hyannis MA 02601 11-9-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 10
❑ 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.):
Leachig is two rows of infiltratos( 5 ea. row)total 10 high cap infiltrator. Ck D Box and camera
out. No sign of over loading or solid carry over.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Nov 10 2015 23:53 Jim The Inspector Man 5085349919 page 32
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
ki -
587 Pitches Way
Property Address
Jennifer Brady
Owner Owner's Name
information is
required for every Hyannis MA 02601 11-9-15
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
1
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Nov 10 2015 23:53 Jim The Inspector Man 5085349919 page 33
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
587 Pitches Way
Property Address
Jennifer Brady
Owner Owner's Name
information is
required for every Hyannis MA 02601 11-9-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:.
® hand-sketch in the area below
❑ drawing attached separately
v �
_3
p-3 33-6
DFCK
O d
:13
t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Nov 10 2015 23:53 Jim The Inspector Man 5085349919 page 34
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
k 587 Pitches Way
Property Address
Jennifer Brady
Owner Owner's Name
information is
required for every Hyannis MA 02601 11-9-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth t 10,
p high ground water: 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: 3-8-10
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:
T.H.on Design plan 3-8-10 no G.W.at 10'. Bottom of leaching at 3' below grade. Bottom of leaching
at 7'above T.H.Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Nov 10 2015 23:54 Jim The Inspector Man 5085349919 page 35
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
'f _587 Pitches Way
Property Address
Jennifer Brady
Owner Owner's Name
information is required for every Hyannis MA 02601 11-9-15
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B. C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t
t5ins•3113 Title 5 Official Inspectlon Form.Subsurface Sewage Disposal System•Page 17 of 17
Nov 10 2015 23:54 Jim The Inspector Man 5085349919 page 36
L7�fiEle �1 Inspetbon ;
CD Informative Inspection
Name, Address:
647i F 'Po
C �y
Yes No
❑ M-____WaS homeowner on-site duri69 inspection?
ection?
0 UUOS a camera used to I®Cate any components?
0 D® you recommend System be pumped?
What components vvere dug'UP?
d Leaching
Details on repairs needed:
COA-A-1 P19.5.5 1ox-
1 S/ X ,�/NFS
1ti Z
bU £R �30x 14R£.4 Ug/eS
TOWN OF BARNSTABLE
LOCATION 577 71 SEWAGE# .14 I0-a.0
VILLAGE �c�j �i� ASSES OR'SMAP&PARCEL 220- cb2
INSTALLER'S NAME&PHONE NO. . F
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) 2 MQi7C6-,r S (size) /O lA]�Z
NO. OF BEDROOMS
OWNER
PERMIT DATE: D COMPLIANCE DATE: loll,
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility feet
Private Water Supply Well and Leaching Facility(if any wells exist
on site or within 200 feet of leaching facility) feet
Edge of Wetland and Leaching Facility(if any wetlands exist
within 300 feet of leaching facility). feet
FURNISHED BY
C
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l�
W
1
i
i
No. Fee V U
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 2pplication for fqogarpqtetu con5tructiott der it
Applic n or�5-Teit to Construct( ) Repair(✓rpgrade( ) Abandon( ) ❑Complete System Individual Components
�,af�
Locati ddress of No. //�1 S &11f Owner's Nam dress,a d Tel.No.
Assessor's Map/Parcel zu r 3 A110
W4 1 J A���''�
Installer's Names,Address,and Tel.No. Designer's Name,Address and Tel.No. 9'�3 KOO& R fj
65 e4 0c7 �� ��. l�'f U�i yfP1�• P°szU
Type o uilding:
Dwelling No.of Bedrooms �� Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building Atq5e No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 330 gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank low Type of S.A.S. clk,i R gmCA� in
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) �442A2�— (/ � ���yG�ir4q Sc,A}'iCJ►�
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 Envir n ental Code and not to place the system in operation until a Certificate of
Compliance has been issued by thi7Boa,.,of Health.SignedDate
Application Approved by Date
Application Disapproved b Date
for the following reasons
Permit No. 20 10 oZf� / — Date Issued 7 6 0
No. S}Tr2 o l/ lam,r
• Fee d 0 �-
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH,DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS' Yes
Zipplication for Oi 5po'!6 Y 6p.5tem- Con.5tructiou Permit
Applic ion'fo�a Pe it to Construct( ) Repair(Upgrade( ) Abandon( ) ❑Complete System Individual Components
r 07
Locatio Adn`dresror� of No. 4;fs Owner's Name,Address�,J/nd Tel.No.
.00
_ Assessor's Map/Parcel 3! �ev I
I q /
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. y�9{3 U& tot �.
Type oAuilding:
Dwelling No.of Bedrooms j Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building 9,95e_ No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 330 gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tatik' Type of S.A.S. �).,h 4L*4A-&iu if)
Description of Soil ' 1
Nature of Repairs or Alterations(Answer when applicable) �/�/ J �� 1/ Q 124G4r?a
' r
Date last inspected:
Agreement:
S
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 Envirdn ental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this7Boaof Health.
i Signed Date
r Application Approved by Date o
" Application Disapproved b Date # `
�j for the following reasons "
Permit No. w X 0 1 Date Issued -71 6 /o Id
THE COMMONWEALTH OF MASSACHUSETTS "
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( ) Repaired ( ZUpgraded ( ' )
Abandoned( )by odh rSH
at 5 7 C, p has been constructed in accordance
With the provisions of Title 5 and the for Dispo al System Construction Permit No. dated 7��-
WhrJ4
rInstaller CN" Designer I�p�.c. '� l2 1►?a�
#bedrooms a qApproved design �3U gpd
t:i The issuance of s pdrmit shall not,be construed as a guarantee that the system ill tionas des gned.
Date '� Inspector r ^)
�- No. ri�trV `2u L'f Fee /�)v�--------- - -THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION — BARNSTABLE, MASSACHUSETTS
Migpoal *pztem Con!5truction Permit
Permission is hereby granted to Construct ( ) Repair ( Upgrade ( _ ) Abandon (r )
System located at 117 kh e K-5 LUIQ
I
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title S and the following local provisions or special conditions.
Provided: Const Cho must be completed within three years of the date of th's pe �it.
Date (0 Approved by
N_ r
-v
Town of Barnstable
T"E r Regulatory Services
Thomas F. Geiler, Director
* BARNSTABLE, •.
MASS. Public Health Division
Thomas McKean,Director
200.Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
9
Date: —7113 I A(D Sewage Permit#261 D Assessor's MaplParcel 2_?O Lz37
Designer: eft P� / 3 !�E Installer: 0�/f
Address:. q�3 g�� ee Address: �-/`L d Mjlp,/7
Hod uo A-7 A-f i4 02e,7,� LI f Gul/Jle6llm�flSl4e' �i �� Q
s issued a permit to install a
(Qfate) (installer)
septic system at !�_8? P/Z rl v� W A--r-' based on a design drawn by
(address)
dated i.6 he w
(designer)
YW , certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box'and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic syste ) but in accordance with State & Local Regulations. Plan revision or
certified as-built designer to follow.
(Installe ' ignature)
d:lVIL
NO.36461
,
6 6 A4.
(Designer's Signature) ( ix De gner's Stamp Here)
pPLEASE"RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
'OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH: THIS FORM AND AS-.
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
QASeptic\Desikner Certification Form Revised.doc
TRANS. NO.:
CITY/TOWN: - � �IS
APPLICANT:
ADDRESS: 5$1 F 1Tr—H 4 S %Az h
DESIGN FLOW: gpd
REVIEWED BY: DATE:
N/A OK NO
,_..-r_....._.. .. ::-»5�+.5.....,,.. ,..,� ,...,.:. 'u .,wr ui>: ;.,. �.,a.a s�„wak.:vs$;'.,.,. !„_K«r sa}.�<'...,ra•�.:f .��':����'£v�,#'�`��:a �',b�' s'���f,�s3 da'�5.'w�..i.� � ��',�.srh;
Legal boundaries denoted [310 CMR 15.220(4)(a)]
Street, Lot, tax parcel number and lot number noted on plan [310
CMR 15.220(4)(u)]
Locus Provided [31.0 CMR 15.2204(t)] +/
Plan proper scale? (1"=40' for plot plans, 1"=20' or fewer for ✓
components) [310 CMR 15.220(4)]
Easements shown [310 CMR 15.220(4)(b)]
System located totally on lot served [310 CMR 15.405(1)(a) for
upgrades]- if not, a variance is required [310 CMR 15.412(4)]
Location of impervious surfaces (driveways,parking areas.etc.)
[
310 CMR 15.220(4)(d)]
Location all buildings existing and proposed 310 CMR
15.220(4)(c)] ✓
Location and dimensions of system components and reserve areas.
[310 CMR 15.220(4)(e)]
System Calculations [310 CMR 15.220(4)(0]
daily flow
septic tank capacity(required and provided)
soil absorption system(required and provided) ✓
whether system designed for garbage grinder
North arrow [310 CMR 15.220(4)(g)] ✓
Existing and proposed contours [310 CMR 15.220(4)(g)]
Location and log of deep observation holes (existing grade el. on
each test) [310 CMR 15.220(4)(h)] ✓
Nantes of soil evaluator and BOH representative [310 CMR
15.220(4)(h) and (i)]
Location and date of percolation tests(performed at proper
elevation?) [310 CMR 15.220(4)(1)]
Percolation test results match loading rate? [310 CMR 15.242]
Certification statement by Soil Evaluator [310 CMR 15.220(4)0)]
Observed and Adjusted groundwater (method for adjustment
given or indicated) [310 CMR 15.103(3) and 310 CMR /
15.220(4)(n)]
Address 270 21 Sheet 1 of 7
r -
ti ,
N/A OK NO
Location of every water supply,public and private, [310 CMR ✓
15.220(4)(k)]
within 400 feet of the proposed system location.in the case ✓
of surface water supplies and gravel packed.public water supply
within 250 feet of the proposed system location in the case _
within 150 feet of the proposed system location in the case
of private water supply wells
Location of all surface waters and wetlands located up to 100 ft.
beyond setbacks listed in 310 CMR 15.211 and any catch basins
located within 50 ft. [310 CMR 15.220(4)(1)]
Water lines and other subsurface utilities located [310 CMR /.
15.220(4)(m)] (if waterline cross see 310 CMR 15211(1)[1])
Profile of system showing invert elevations of all system
components and the bottom of the SAS [310 CMR15.220(4)(o)]
Stamp of designer [310 CMR 15.220(1) and 310 CMR 15.220(2)]
Stamp of Registered Land Surveyor(required if construction
activities within 5 ft. of lot line) [310 CMR 15.220(3)]
Test Holes adequate (two in each of the primary and reserve
unless trenches as permitted in 310 CMR 15.102(2)or as
approved for an upgrade under LUA at 310 CMR 15.405(1)(k)]
Test hole adequate to demonstrate four feet of f suitable material?
[310 CMR 15.103(4)] .
Test Holes adequate to confirm adequate groundwater.separation?
[310 CMR 15.103(3)]
Benchmark within 50-75' of system [310 CMR 15.220(4)(q)]
Materials specifications noted? [various sections of 310 CMR /
15.000] V
System components not> 36" deep (unless Local Upgrade
Approval or LUA requested) [310 CMR 15.405(1(b)]
Address 2'7b 12 -7 Sheet 2 of 7
N/A OK NO
:PayRNM
size OK? [310 CMR 15.223(1)]
Inlet tee located ten inches below flow line [310 CMR 15.227(6)]
Outlet tee 14" or 14" + 5" per foot for increase ft depth[310 CMR /
15.227(6)] ✓
Outlet tee with gas baffle or approved filter [310 CMR 15.227(4)]
Note regarding installation on stable compacted base [310 CMR /
15.228(1)]
Separation between inlet and outlet tees (no less than liquid
depth) [310 CMR 15.227(2)]
Inlet/Outlet elevations at least IT' above high groundwater
(except as described 310 CMR 15.227(5)) or permitted for j
upgrades under LUA [310 CMR 15.405(1)(k)] o/
Minimum cover 9" (Tanks buried more than 9" must have risers
on all openings and on the d-box) [310 CMR 15.2228(1) and 310 V
CMR 15.232(3)(f)]
Three access covers (inlet and outlet must be 20" or greater) - /
middle access at least K' b 7/07 310 CMR 15.228(2)]
Access to within 6 ",of grade, - one port for systems<1000gpd;
two for systems >1000 gpd [310 CMR 15.228(2)] ✓
All at-grade covers secured to unauthorized access? [310 CMR
15.228(2)]
> 10 ft from building foundation [310 CMR 15.211{1)]
Buoyancy calculation Required/Done [310 CMR 15.221(8)]
H-20 Where appropriate? [310 CMR 15.2M(3)]
Setbacks from-resources,[3 10 CMR 15.211J
" . 't"""'bs..C't
Multi Compar=t�rnentTans ��
a-z
Required when other than single-family dwelling or flow>1000
gpd [310 CMR 15.223(1)(b)]
First compartment 200% daily flow; Second compartment 100%
daily flow 310 CMR 15.224(2) and 3
"U" pipe through or over baffle, outlet of each compartment with
gas baffle or approved filter [310 CMR 15.224(4)]
Address `Z'ZD Z3'7 Sheet 3 of 7
N/A OK NO
a»�w srz�_..,®,esa;;r.�,m.E.�..�.5�.�.>.ro-kt,m'.�x ,rupo-cv ,,,,,ax'f�9 u» &e.� his ,rno?s.$•x�_.�',»,.,��.,s„-,«oe ,� .+ra.k
Located at least ten feet from any water line? [310 CMR /
15.222(2)]
Disposal piping at least 18" below water line(when water.and /
sewer cross, see 310 CMR 15.211(1)[1])
Cleanouts required/provided? [310 CMR 15.222(8)]
Thrust blocks specified in force mains?310 CMR 15.221(6)(c)]
Slope of sewer line not less than 0.01 (1/8"/ft) 0.02 preferable /
[310 CMR 15.222(6)] ✓
Proper pitch on all runs? (.005 within gravity-distributed trenches
and beds) [310 CMR 15.251(9) and 310 CMR 15.252(2)(c)]
Siphon problem/(leachfield below pump chamber)
Endcaps or vent manifold specified?
Size and orientation of discharge holes specified? (not smaller
than 3/8" not larger than 5/8") [310 CMR 15.251(8) and 310
CMR 15252(2)(h)] ✓
Materials specified (310 CMR.15.251(5) specifies various pipe
types allowed) ✓
q�.��`�
Stable compacted base [310 CMR 15.221(2) and 310 CMR
15.232(2)(a)]
Splash plate or baffle tee required on inlet/provided? (when
pressure sewer to d-box or steep pitch of gravity sewer) [310 /
CMR 15.323(3)(a)]
Riser if deeper than 9" [310 CMR 15232(3)(f)]
Inside minimum dimension 12" [310 CMR 15232(2)(b)]
Minimum sump 6 [310 CMR15.232(3)(e)]
Watertight cover if<2000gpd); waterproof manhole if>2000gpd /
[310 CMR 15.232(3)(d)] V
Capacity(emergency storage above working--design flow)? [310
CMR 231(2)]
Proper setbacks [310 CMR 15211 (same as septic tanks)]
Watertight 20-in minium access manhole at least 20" MUST BE
TO GRADE [310 CMR 15.231(5)]
Service components accessible(not too deep with piping,
disconnects accessible)
Alarm floats - alarm on circuit separate from pumps specified?
Exceeds two units must have two pumps operating in lead-lag
mode. [310 CMR 15.231(6) and(8)]
Stable Compacted Base [310 CMR 15.221(2)]
Buoyancy calculations needed? Provided? [310 CMR 15.221(8)]
Address Z'7G123 7 Sheet 4 of 7
N/A OK NO
f � � '°�" � A' ✓fix .'� bAi k 5
NSOII,;ABSORPIOSYSTES�sAS) GEN,E
Calculations correct?
4 feet of naturally occurring material demonstrated? [310 CMR ✓
15.240(1)]
Required separation to groundwater? [310 CMR 15.212)]
Aggregate specified as double washed[310 CMR 15.247(2)]
System Venting required/provided? (system.under driveway or
>36" deep) [310 CMR 15.241] ✓
Inspection ports specified and within 3"final grade? [310 CMR /
15.240(13)] ✓
Breakout requirements met? (No violation of breakout elevation
within 15 ft of SAS unless barrier) [310 CMR 15.211(1)[4] and
Guidance Document]
Chambers and Gal. in trench configuration supplied with inlet ^
every 20 ft. [310 CMR 15.253(6)]
Each structure with one inspection manhole(if>2000 gpd must
be to grade) [310 CMR 15.253(2)]
Aggregate 1' minimum- 4'maximum. [310 CMR 15.253(1)(b)]
2' sidewall credit maximum [310 CMR 15.253(1)(a)]
In bed configuration, inlet every 40 sq. ft. [310 CMR 15.253(6)]
�'RENCHE31 OCVI25 25 �
4�w, ra;,s'
Width 2'minimum 3'maximum [310 CMR 15.251(1)(b)]
100 feet- maximum length [310 CMR 15.251(1)(a)]
Minimum separation 2x effective depth or width whichever /
greater(3x if reserve between trenches) [310 CMR 251(1)(d)]
Situated along contours [310 CMR 15.251(2)]
Breakout OK? [310 CMR 15.211(1)[4] and Guidance Document]
x-
minimum 2 distribution lines [310 CMR 15.252(2)(a)] "
Maimium separation between lines 6' [310 CM R15.252(2)(d)]
Maximum separation between lines and outside of bed 4' [310
CMR 15.252(2)(e)J
Aggregate depth below discharge pipes 6" minimum, 12"
maximum. [310 CMR 1.5.252(2)(g)]
Separation between beds 10'minimum: [310 CMR 15.252(2)(f)]
Bottom area used in calculations only [310 CMR 15.252(2)(i)]
Address 220 AS 7 Sheet 5 of 7
N/A " OK NO
DIDTHELt Me Me
� �
bMa .&. RUN,,,
>. v
Pressure Dosed System? Provided pump and piping
calculations as required [310 CMR 15.220(4)(r)]
Pressure dosing required on all.systems>2000gpd or alternative
systems under remedial approval [310 CMR 15.254(2) and I/A
Remedial Use Approvals]
If used in gravelless system -make sure jet is.directed as not to j
scour soil interface [Guidance Document]
Inspections once per year(systems<2000 gpd)or quarterly /
(>2000gpd) good to note on plan [310 CMR 15.254(2)(d)] �/
Construction in fill - Did the plan specify that the fill shall meet
the specification of 310 CMR 15.255(3)?
Impervious barrier and/or retaining wall ? [Guidance Document]
Impervious barrier installation must be supervised by /
designer [310 CMR 15.255(2)(b)]
Retaining wall must be designed by Registered Professional
Engineer [310 CMR 15.255(2)(a)] V
Side slope not exceed 3:1 ? [310 CMR 15.255(2)]
Breakout requirements.met? [310 CMR 15.252(2) and
Guidance Document]
At least 5 ft. from impervious barrier to edge of SAS (10 ft.
recommended) [310 CMR 15.255 (2)(e)]
Gra elless ysteni ., A P alb e s 01IM- 1 t <-
Check DEP Approval letters for credits and design conditions
If used with pressure dosing do not allow pressure discharge
to scour soil interface
Was DEP Approval Letter provided and/or have you
reviewed the letter for conditions?
Is the technology being properly applied and does it meet all
DEP Approval Conditions?
Is there a note on the plan regarding the requirement for
perpetual maintenance agreement?
Any alarms involved on separate circuits
Did the applicant submit an operation and maintenance
manual? a
Has applicant submitted a copy of a maintenance
#.t�.ro*wxc�;:� .r.x..�:ron`I„ •.Fza.et a.M a.�w. � �:e y�����. °Y��,. .-�-
Are the variances listed on theplan ? [310 CMR 15.220 J
(4)(q)]
RLS Stamp necessary on plan if a component is within five
feet of property line [310 CMR 15.412(4)]
New construction or increased flow proposed- [Refer to 310
CMR 15.414]
Address "2?a�23? Sheet 6 of 7
N/A OK NO
6-"a Y ,.fi:Yx P.t )^xb¢eas '" z' 4j R `�w',E"' db° ram. YaS y^ 4 } �
INitroger"'NeW iiveKA Q /�k W. � � ,` r w a_r<'il3ZC' 5 3 W F�.�+` ..�,�aZS "G✓,�s. "e .3'�.nf.H,'Y.( .4 . N: Y%xt,a
Is the system in a Designated Nitrogen Sensitive Area(Zone 11 for
a public supply well)? [310 CMR 15.214, 3.10 CMR 15.215 and /
310 CMR 15.216 - also refer to Policy regarding upgrades of such /
existing systems]
Is the system proposed on the same lot as served by private well ? /
[310 CMR 15.214(2)] V
Are the nitrogen loads proposed in compliance? [310 CMR
15.216(1)]
`p��wq ��x�x :�-L'�Y Y�"✓�"i• Yf ..�"
tz�� an_ � � ,..... n.
Pumping to septic tank ? [ 310 CMR 15.229]
Shared System [310 CMR 15.290] "
i
Address_ 27t /23 7 Sheet 7 of 71
No.. ••--
THE COMMONWEALTH OF MASSACHUSETTS
BOARD I EA Lj
T
OF.... ........................:...... ....
ApV irtttiun-fur Biipuual Workli Cn nlitrurtiun Vrrniit
pplication is hereby'made for_a Permit to Construct A�®rRepair ( ) an Individual Sewage Disposal
Syst t: ��
''� r/' -` - - -------ae«-------------------------•-----...------
w Locat'o -:Address or Lot Nor.
vy/ /%�' Address
a ...!-4 ..... j/ . .....................•...... ...............------..............se! :'��v..Lf....
Installer Address
Q Type of Building Size Lot.....���. 13.-'��-_Sq. feet
U Dwelling—No. of Bedrooms------------ ----_____________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building -_----_.--_--------------- No. of persons............................ Showers ( ) — Cafeteria ( )
0.' I Other fixtures .........
W Design Flow------------ s. .....................gallons per person per day. Total daily flow.............X0------_____-__----._...gallons.
WSeptic Tank—Liquid capacitV4"-gallons Length---------------- Width................ Diameter_.----_-.._---_ Depth.__._-._.-----
x Disposal Trench—No..................... W dth.__..__...__..__._.. Total Length........ _. Total leaching area......._.....__..._.sq. ft.
Seepage Pit No...../ _._____-�`— `-_____.__ eYl 'Rlo� t ,`fP� :.._: Total leaching area._ .a ._sq. it.
Z Other Distribution box ( Dosing tank ( ) p �--�G���f .2 -2-3-77
aPercolation Test Results Performed by-----------------------------------------------•----•-•-- Date............. ............-------------
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
1:14 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water-------------.----------
a0 --------- t
Description of Soil-------Qt _= ... p
V -------------------- ._'_-..Z.._.__ _ .Gf___'1 __.C° <e 'Ga,e.� -_-_ _.,7.`�.1 '_
------------------------------------------------------------- --•--•---••---•----------------------•-------.--------------------•--••-•-----•-----------•-•----------------- •------•---•-----••-----
U Nature of Repairs or Alterations—Answer when applicable....------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------------------------------------- ...................... ---------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article \I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of hea .
C
- -------- -- .= . --- �- .....�� d.....
Date
Application Approved By--•----•• . --- --- ..... Zt44l/ ---------------------------------- ----- 7--7-------
Date
Application Disapproved for the following reasons:................................................................................................................
---•-----------------------------------------------------------------------------------••-----------.......-------------------------------------------------------------------------•-------------------
Date
PermitNo.-- ..................................................... Issued----- 7 - -•--••-••--••••-•••••--.....
Date
s ----_ —________________________________:--______________________-__ -----------
NA:;:.... Fimx/.::'..................._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
AVVIirFation -for Ditywial Workii Tatutrurti n Vrrufit
Application is hereby'made for a Permit to Construct (for Repair ( } an Individual Sewage Disposal
System:at• ,
�ri J j�• 1 //•��i'Lf.....:cL_ '.---' ..
Location or Lot No:
!...................................................t='-l`- ...... ......................... ---..................----- ..?...... -n-1..... •-----.......---.._.....-----...
Owner Address _ /(c a ...__..__E. ..{--./..... ------- Y!/? --'/--•••---••-•-------
Installer r Address
UType of Building -" Size Lot------- feet
�-, Dwelling—No. of Bedrooms...___.....�---------------------------Expansion Attic ( ) Garbage Grinder ( )
pa.-, Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures ----- " -� _
W Design Flow___.___.._.. _t--�----------------------gallons per person per day. Total daily flow-------------- ...........................gallons.
1:4 Septic Tank—Liquid capacity llons Length---------------- Width-- ............. Diameter...........----- Depth-.--------------
xDisposal Trench—No--------------------- Width---------------- -. Total Length--------- '------- Total leaching area-------.------._....sq. ft.
Seepage Pit No ���_�'-`___- Diamete'�"-:__-___-__�Depth",below=inlet' ` . Total leaching
Z Other Distribution box ( )-'� Dosing tank ( ) p'X- OZ ` .2-a.$'T-/
Percolation Test Results Performed by-------------------------------------------------------------------------- Date----------------------------------------
Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth,to ground water.--.-.---___.._---_--
f4 Test Pit No. 2----------------minutes per inch Depth of Test Pit------------------.. Depth to ground
W
-
-.4.1.'
--,�1- ---'
- -- ------------------w--a•'-t•e--r-------------------------
Ix ----------- -- ----
------ --R-------- ----•----------•a••-•••••,-XO Description of Soil------- Y �Ft _±----r A -----
------------------- --� 7
U Nature of Repairs or Alterations—Answer when applicable.-------------------------------------=--------------------------------------------------------
: .
•--------------------------•---------------------------•--------------------------------•-•-------------------------- ------------.---•--•----------------•- ••-----------------------•-----------
Agreement: �'
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sig d ,. , ..1. •�. t ibf�~r/st < - tip-- / :.%�
Date
y
Application Approved B --`- �s" = dtrV1 --- --- --_----- ----a_`!2.t�'7 7------
Date
Application Disapproved for the following reasons:--------------------------------------------------------------------------------------------------------------
•------------------•••---••-••••--•--------•--••-----------••-•....-----------------------------------------------
Date
Permit No..-•-•-•......-•-•-•-=.............................._.. Issued.............................. -=--- -----------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD�OF 'HEALLTH,
......OF...............:.....................................................................
. �r�tif ir�tr aaf�_f��ut�li�a�r�e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (� or Repaired ( )
- Installer
at.... = �'------------ =-----=r---------•-- �G2`:---/!�- --------------•--•----=f----, .--r -. ............--•--._.....--••--•--••-•--
has been installed in accordance with the provisions. of;�", I XI of: The State Sanitary Code as described in the
application for Disposal Works Construction Permit No. _.... 3 PP P l�• ---------------- dated------�" y=
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector.......................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
---- BOARD OF HEALTH
......�...'r'...... `.. .....OF.-- ..-..... F�_,a . (t ...................... _.
N&•-•••--- FEE:!`:5.------....------
�i��n��tt1�-• �rk,� �C��a��,trr�rti�at° rra�tit
Permission is reby granted `_--_«&?lrA.V_.%_------. 'f`=f`- `"G.,��
-- - ---- ----------------
to Construct �) or Repair ( ) an-Individual Sewage Disposal Syst�5e /
at No. ' ----�--------------- . 7'.: .a !
rZStreet
as shown on the application for Disposal Works Construction P it No Dated------L?- _ -.7?--_••.-••-•
y `}
1 V= Lt tq ----_---
.._.----_-•.................... Board of Heal
-----------------------_--
DATE................................................................................ -
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.APE 1ti/rp T�)t:
Town of Barnstable Barnstable
Regulatory Services Department a
asxivst:4s�,
MAS& Public Health Division
039. ♦�
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#70081830000205008949
2/16/2010
Charles J. Cutler Jr.
5602 Colwyck Drive
Richmond, VA 23223-5810
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 587 Pitcher's Way, Hyannis MA was last inspected on
January 14, 2010 by Mark Polselli, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Failed"under,the guidelines
of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Backup of sewage into facility or system component due to an overloaded or
clogged SAS.
You are ordered to repair or replace the septic system within Sixty (60) days.from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action:
PER ORDER OFT . E BOARD OF HEALTH
y
Tl10-_ _ cKea , O
Agent of the Board of Health 0 D M
p
1
Commonwealth of Massachusetts
MM
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address -74
G�Grle-5
Owner Owner's Name
information is required for 9!�ann f
every page. City/Town P' State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms the
computer.use 1. Inspector: Q
only the tab key
to move your /1, �G✓`K / v�S���
cursor-do not Name of Inspector
use the return -
key.
Company Name
,foo AV-
Company Add 174FS�4 a417
City/Town p
State ZI Code
Telephone NuInber 7 Ucense 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 Section15.348 of
Title 5(310 CMR 15.000). The system: µ ^
'I RZE
'2 1
El Passes ❑ Conditionally Passes ~Fails U0 C
❑ Needs Further Evaluation by the Local Approving Authority
— 4
Insp tor's Slgnature 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.
f (,i5ins•09ios vI V
Tide 5 Official Inspection Form:Subsurface Sewa Disposal system•Page 1 of 17
t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal JSystem Form-Not for Voluntary Assessments
S—6
Property Address
Cam► f/ems
Owner Owner's N
information is 717G��fs 016 0/
Ao
required for ��every page. CitylTovm State Zip Code Date ctlon
B. Certification (cunt.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ one or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes","no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank Is replaced with a complying septic tank as approved by the
Board of Health.
•A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal /System Form -Not for Voluntary Assessments
Property Address
GN7��e r
Owner Owner's Name,
information is H
required for f'I a ti>7i AW 6 0/
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cunt.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
El obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines In accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
15ins•09/0e
Title 5 Official inspection Form Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address C,4 4/e
Owner Owner's Name
information is G f odL 0l
required for
every page. citylTown Gt 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 coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen Is equal to or
less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ❑/ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6"below invert or available volume is less
than Y2 day flow
15ins•09/08 Title 5 official Inspection Forth:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
/> P,Jc 4ee/
Property Address
Owner Owners Name
information is o ellN hI f ledoa
required for
every page. Cityrrown C7, State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ 0/ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ 0� Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ L=� Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Lid' 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 coilform 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 falls. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
UVSubsurface Sewage Disposal System Form -Not for Voluntary Assessments
S62 P/ C t"I'q
Property Address
Owner Owner's Namq ,
information is H ,/
required for
every page. cityfrown 011 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
❑ L7 Pumping information was provided by the owner,occupant, or Board of Health
❑ LVJ Were any of the system components pumped out in the previous two weeks?
❑ L�" 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?
L ❑ Was the site inspected for signs of break out?
L�" ❑ Were all system components, excluding the SAS, located on site?
L� ❑ 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): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
15ins•09/08 Title 5 Official Inspecction form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
qgmo Title 5 Official Inspection Form
MMUMM Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
IV
Property Address —_
Owner Owners N me
information is required for 0ol n a i e, �'1L0 L 0/ 'I y-1/0
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
/0170
Number of current residents:
Does residence have a garbage grinder? ❑ Yes El""No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes M- No
Laundry system inspected? ❑ Yes No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes E; _o
Last date of occupancy: Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: —
15ins•09/06 Tine 5 Official inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Sgr7 PNe-1,0#4- 4,142
Property Address 1
Owner Owner's N71�1
,
information is �/� _ da6D — /5/—/O
required for h Q'^ 1 J
every page. city/rown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of S em:
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):
15ins•09/08 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 0 o1 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' �� (/'�TG hBrs G✓G
Property Address
Owner owners Name
information is G r►►'!i r /� oa o/ I—/4/-/0
required for 9-13
every page. City/Town C7 State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date in Ile (if known)and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes L9�o
Building Sewer(locate on site plan): l
Depth below grade: /
feet
Material of construction:
ast iron 0 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: feet
Material nstruction:
oncrete El 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:
.15ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Pro Address Property p---
Owner Owners NaA2amolf-
information is D
required for
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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? l C^ZV/Ge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.):
. 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
15ms•09008 Title 5 Of ial Inspection Form:Subsurface Sewage Disposal System•Pape 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
557 P-�c
Property Address
Owner Owner's Name
information is Q NN �� (� 6 p/ —l y�O
required far
every page. CiWrOwn 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
15ms•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Elmo Title 5 Official Inspection Form
Subsurface Sewa/gye Disposal-,)
Form -Not for Voluntary Assessments
Sd / 0 ,TG
Property Address /
Ctn lam'✓
Owner Owners Name
information Is �a nri i l /�i4 0o60/
required for
every page. Cityrrown State Zip Code Date of Inspedon
D. System Information (cunt.)
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.):
/'A0' �-- '9 X
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:
!Sins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Pape 12 01 17'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
• S�� �/ G`'1 erf Gt/�
Property Address
Owner Owner's Name
information is
required for 91':::�4 n I
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.) pe-
Type: 6 X fo
leachi
ng i number: 6)
9Pis
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
El 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.):
pH dIH % �ql,n{cl/ 0 lkive;-
G
Cesspools(cesspool must be pumped as part of inspection)(locate on site plane
Number and configuration
Depth-top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
15ins•09108 l Ti Us 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of'J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Owner Owners Name
requrired t�oris L /� - 0--)6O� / —A/ /a
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15ins•09106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
S��
Property Address L
Owner Owners Name
information isA �i� Oa 6�
required for h N r
every page. City/Town G>1 State Zlp Code Date of inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
hand-sketch in the area below
❑ drawing attached separately
114
V3
i5ins-09108 Tide 5 Official in specUan Form:Subsurface Sewage Disposal System•Page 15 of 17
I
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal Sys/tem Form -Not for Voluntary Assessments
Property Address
Owner Owner's Name
information is
required for �`�OR N r t
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
❑ Check Slope I
/ 0
❑ Surface water �7
1
❑ Check cellar
❑ Shallow wells Cbf �
ley
Estimated depth to high ground water: 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:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
i5ins-09fo0 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 18 of 17'
I
Commonwealth of Massachusetts
lug -tr)Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
?-� , / �6
Property Address
Owner Owners Name
information is Al
/J�
required for / vl v 1 / /l 0.1 A p�
every page. city/rown State Zip Code Date of Inspection
E. Report Completeness Checklist
Inspection Summary:A, B, C, D,or E checked
Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
Sys
Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
15ins•09M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
vim, 77
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