HomeMy WebLinkAbout0660 PITCHER'S WAY - Health i60 PITCHER'S WAY, HYANNIS
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I
Commonwealth of Massachusetts 0?w— I
Title 5 Official Inspection Form
tiw Subsurface Sewage Disposal S stem Form - Not for Voluntary° 9 p Y Assessments
660 Pitcher's Way
u Property Address t ::
Juan and Svetlana Marichal
Owner Owner's Name/
information is H annis ✓ MA 02601 10/01/2020
required for every �
page. City/Town 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 forms A. Inspector Information
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
52 Rivers End Road
Company Address
Teaticket Ma. 02536
City/Town State Zip Code
r� 508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
10/04/2020
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18
Ya
Commonwealth of Massachusetts
Title 5 Official Inspection Form
I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
660 Pitcher's Way
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is Hyannis MA 02601 10/01/2020
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This 3 bedroom home has an H=10 1000 gallon septic tank feeding a leaching pit with stone. At the
time of the inspection no visible failure criteria was found.
2) 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):
i
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
r
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
660 Pitcher's Way
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis annis MA 02601 10/01/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ~
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) 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.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
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r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u
660 Pitcher's Way ..nit
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis MA 02601 10/01/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ 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
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health','
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
El Discharge or ponding of effluent to the surface of the ground or surface waters
® due to an overloaded or clogged SAS or cesspool
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�<iI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
............ !% 660 Pitcher's Way
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis MA 02601 10/01/2020
page. CitylTown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 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.
5) 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 CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
660 Pitcher's Way
V
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis MA 02601 10/01/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
{ threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate"yes" or"no"for each of the following for aH inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received 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'Ias
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)]
I
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c !% 660 Pitcher's Way
u
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis MA 02601 10/01/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus
GPD
Description:
Number of current residents: 4
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes 0 No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d town water
9 ( Y 9 (gp ))�
Detail:
In 2019-57,596 gallons were used and part of 2020-59,840 gallons have been used.
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u-
660 Pitcher's Way
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis MA 02601 10/01/2020
-
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
�- I1!P Title 5 Official Inspection Form
11
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
660 Pitcher's Way
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis MA 02601 10/01/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1977
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
19"
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Water was flowing at the time of inspection.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
660 Pitcher's.Way
V�
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis MA 02601 10/01/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 12"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:
H-10 1000 gallon
Sludge depth:
3"
Distance from top of sludge to bottom of outlet tee or baffle
33"
Scum thickness 2„
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined?
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.):
I recommend the new owner put the septic tank on a maint. plan with a local septic pumping co.
based on the future use of the home. At the time of inspection the liquid level was at working level
and the baffle was in place.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
Commonwealth of Massachusetts
�� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u 660 Pitcher's Way
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis MA 02601 10/01/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u�
660 Pitcher's Way
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis MA 02601 10/01/2020
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
I ran a camera down the discharge pipe and did not see a D-Box.
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
660 Pitcher's Way
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis MA 02601 10/01/2020
-
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: one
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
r� p Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
660 Pitcher's Way
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis MA 02601 10/01/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At the time of the inspection there was apx 4' of ponding water and no visible failure criteria was
found.
12. 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
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ylb Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
I
660 Pitcher's Way
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis MA 02601 10/01/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Il
Commonwealth of Massachusetts
,p Title, 5 Official' Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
660 Pitcher's Way
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis annis MA 02601 10/01/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
hand=sketch in the area below ,
❑ drawing attached separately
i
r
n
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
tip Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
660 Pitcher's Way
V�
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information fo is Hyannis MA 02601 10/01/2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) '
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 12 plus feet
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:
I augered a hole at a lower elevation and shot it with a transit.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
I Title 5 Official Inspection Form
_ I, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
u—
660 Pitcher's Way
Property Address
Juan and Svetlana Marichal
Owner Owner's Name
information is required for every Hyannis MA 02601 10/01/2020
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
Important:
When filling out 1. Property Information:
forms on the
computer,use 660 Pitcher's Way
only the tab key Property Address
to move your Today Real Estate
cursor-do not
use the return Owner's Name
key. 1533 Falmouth Road
Owner's Address
Centerville MA 02632
Cityrrown State Zip Code
Date of Inspection: Date 08
Date
2. Inspector:
MR. ROBERT A. DRAKE
Name of Inspector
KCJ ENGINEERING
Company Name
66 GREENVILLE DRIVE
Company Address
ORESTDALE MA 02644
U-I ity/rown State Zip Code
08-477-5048
- 'relephone Number
t - 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
-r.,was performed based on my training and experience in the proper function and maintenance of on site
�VV sewage disposal systems. I am a DEP approved system inspector pursuan ction 15.340 of
Title 5(310 CMR 15.000).The system: H pF M�ss9
® Passes ElConditionally Passes ��ails�TA
cl l:F
Eleedrs Further Evaluation by the Local Approving Authority o cR,1L
A •� � jq- Q No.4'1642 �1
1 �� `chi
Inspector's Signature Date FSS/pNAI_EN��,
The system inspector shall submit a copy of this inspection report to the App o I 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.
660 Pitchers Way-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
660 Pitcher's Way
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/09/08
Owner's Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
All components appear to be structurally sound and working properly. No signs of leakage or
blockages.
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.
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 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.
ND Explain:
660 Pitchers Way-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
` Subsurface Sewage Disposal System Form
�M
A. Certification (cunt.)
660 Pitcher's Way
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/09/08
Owner's Name Date of Inspection
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
❑ 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:
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
660 Pitchers Way-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M yv0y`
A. Certification (cont.)
660 Pitcher's Way
Property Address
Hyannis MA 02601
City/Town State Zip Code
Today Real Estate 02/09/08
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (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 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:
I
660 Pitchers Way-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
660 Pitcher's Way
Property Address
Hyannis MA 02601
Cityrrown State ZipCode
Today Real Estate 02/09/08
Owner's Name Date of Inspection
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 '/z 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.]
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.
660 Pitchers Way-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
660 Pitcher's Way
Property Address
Hyannis MA 02601
City/Town State Zip Code
Today Real Estate 02/09/08
Owner's Name Date of Inspection
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.
660 Pitchers Way-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
... ...... ..
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
660 Pitcher's Way
Property Address
Hyannis MA 02601
Cityfrown State Zip Code
Today Real Estate 02/09/08
Owner's Name Date of Inspection
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(3)(b)]
660 Pitchers Way-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
y Subsurface Sewage Disposal System Form
C. System Information
660 Pitcher's Way
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/09/08
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage(gpd)): 141 gpd
9 ( Y 9
Sump pump? ❑ Yes ® No
Last date of occupancy: July 2007
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
f
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:
Last date of occupancy/use: Date
Other(describe):
660 Pitchers Way-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8of16
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
660 Pitcher's Way
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/09/08
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: N/A
gallons
How was quantity pumped determined? N/A
Reason for pumping: N/A
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:
House built in 1977. System appears to be original.Town Of Barnstable Health Department records.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
660 Pitchers Way-T51NSP1.DOC.doc.•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cunt.)
660 Pitcher's Way
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/09/08
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: approx. 2.0'
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
Joints appear to be structurally sound, no signs of leakage.
Septic Tank(locate on site plan):
Depth below grade: 0.75
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Top of Tank approx. 0.75' below grade. Tank appears to be structurally sound and functioining
properly.
If tank is metal, list age: N/A
years
Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No
certificate)
Dimensions: 1,000 Gallon
Sludge depth: Less than 1"
PP
Distance from top of sludge to bottom of outlet tee or baffle approx. 30"
Scum thickness Less than 1"
Distance from top of scum to top of outlet tee or baffle approx. 8"
Distance from bottom of scum to bottom of outlet tee or baffle approx. 17"
How were dimensions determined? MEASURED IN FIELD
660 Pitchers Way-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
660 Pitcher's Way
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/09/08
Owner's Name Date of Inspection
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
All components appear to be structurally sound and working properly. The existing concrete tees are
in place and appear to be in good working condition.Water level at invert of outlet pipe.
Grease Trap(locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
660 Pitchers Way-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
660 Pitcher's Way
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/09/08
Owner's Name Date of Inspection
Tight or Holding Tank(cont.)
Dimensions: N/A
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.):
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert N/A
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.):
No D-Box present.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
660 Pitchers Way-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
660 Pitcher's Way
Property Address
Hyannis MA 02601
City/Town State Zip Code
Today Real Estate 02/09/08
Owner's Name Date of Inspection
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 1 - 1,000 gallon
❑ 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.):
Existing leaching pit appears to be functioning properly. Bottom of pit is damp, stains on wall approx.
1'off bottom.
660 Pitchers Way-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
660 Pitcher's Way
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/09/08
Owner's Name Date of Inspection
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration N/A
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
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction' N/A
Dimensions'
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
660 Pitchers Way-T5lNSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
b
C. System Information (cont.)
660 Pitcher's Way
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/09/08
Owner's Name Date of Inspection
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.
F R,,. .
dick
Pr 6
O
d r A
o --
Z. `
0
660 Pitchers Way-T51NSP1.DOC.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
660 Pitcher's Way
Property Address
Hyannis MA 02601
Cityfrown State Zip Code
Today Real Estate 02/09/08
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
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:
Barnstable GIS Groundwater Maps indicate high groundwater elevation is at approx. =28', GIS
Contour Maps indicate ground elevation is at approx.49', Approximately 21'of separation between
ground and high ground water. Approximately 10' + separation between bottom of SAS and HGW.
660 Pitchers Way-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
Town of Barnstable
OF 1HE Tp�
Regulatory Services
snRr,srAB► Thomas F. Geiler,Director
•erE16,19.
Dry�p�A Public Health .Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
ir A,
t III i-A a Commonweotth of Massachusetts John Grad
Executive Office of Erwironmental Affoifs D.E.P. Title V Septic Inspector
Department of P.O. Box 2119
Environmental Protection Teaticket, MA 02536
(50 - Q
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM AA
PART A H �C7W p
CERTIFICATIONIle
�P O
,9
Property Address: 660 Pitcher Way Hyannis Address of owner: r° pq�FeAq 199� 4t
Date of Inspection:3110197 (If different) ti �afPlT�IE 4
Name of Inspector:John Gracl Gloria Delcore:22 Gladstone St.Evert
Company Name,Address and Telephone Number:
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 inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
X Passes This Inspection is based on criteria defined in Title V
_ Conditionally P sses code 310 CMR 15.303.My findings are of how the system is
_ Needs F h valuation By the Local Approving Authority performing at the time of the Inspection.My Inspection does
not Imply any warranty or quarantee of the IongevltV of the
Fails septic system and any of its components useful life.
t
Inspector's Signature: Date: V7197
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. 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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B.C,or D:
A] SYSTEM PASSES:
X I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion
of the replacement or repair,passes inspection.
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,cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved
by the Board of Health.
(revised 11115195)
One Winter Street 9 Boston,Massachusetts 02108 • FAX(617)556-1049 . Telephone(617)292-5500
_ II
I
t'
S
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 550 Pitcher Way Hyannis
Owner: Gloria Delcore:22 Gladstone St.Evert Ma
Date of Inspection:3110197
Sewage backup or breakout or high static water level observed in the distribution box is due to a broken,
settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] 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 the public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is within a Zone 1 of a public water
supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water
supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private
water supply well,unless a well water analysis for coliform bacteria volatile organic compounds indicates that the well is
free from pollution for that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm.
3) OTHER
D] SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 11115195)
2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 660 Pitcher Way Hyannis
Owner: Gloria Delcore:22 Gladstone St.Evert Ma.
Date of Inspection:3110197
D) SYSTEM FAILS(continued)
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 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Numbers of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area (IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11115195)
3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 660 Pitcher Way Hyannis
Owner: Gloria Delcore:22 Gladstone St.Evert Ma
Date of Inspection:3110107
Check if the following have been done:
x Pumping information was requested of the owner,occupant, and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
n►aAs built plans have been obtained and examined. Note if they are not available with NIA.
x The facility or dwelling was inspected for signs of sewage back-up.
x The system does not receive non-sanitary or industrial waste flow.
x The site was inspected for signs of breakout.
x All system components,excluding the Soil Absorption System,have been located on the site.
x The septic tank manholes were uncovered,opened, and the Interior of the septic tank was inspected
for condition of baffles or tees,material of construction,dimensions, depth of liquid,depth of sludge, depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
x The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 11115195)
4
I .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 650 Pitcher Way Hyannis
Owner: Gloria Delcore:22 Gladstone St.Evert Ma.
Date of Inspection:3110197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 330 gallons
Number of bedrooms: 3
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): Yes
Water meter readings,if available: nla
Last date of occupancy: summer
COMMERCIAL/INDUSTRIAL:
Type of establishment: nla
Design flow:0 gallons/day
Grease trap present:(yes or no) No
Industrial Waste Holding Tank present: (yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings,if available: nla
Last date of occupancy: n1a
OTHER:(Describe) nla
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System has not been pumped in the last two years.
System pumped as part of inspection:(yes or no)No
If yes,volume pumped: 0 gallons
Reason for pumping: n1a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes,attach previous inspection records,if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source information:
Approximately 20 years.
Sewage odors detected when arriving at the site:(yes or no) No
(revised 11115195)
5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 660 Pitcher Way Hyannis
Owner: Gloria Delcore:22 Gladstone St.Evert Ma.
Date of Inspection:3110/97
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 8"
Material of construction:X concreate_metal_FRP_other(explain)
Dimensions: L 9'6'H 5'7"W 4'10'
Sludge depth:6'
Distance from top of sludge to bottom of outlet tee or baffle: 21'
Scum thickness:2'
Distance from top of scum to top of outlet tee or baffle:6'
Distance form bottom of scum to bottom of outlet tee or baffle: 16•
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
Septic tank and all components are structurally sound.Recommend pumping system now and then maintained everyone to two years.
GREASE TRAP:_
(locate on site plan)
Depth below grade: n1a
Material of construction: _concrete_metal_FRP_other(explain)
Dimensions: n1a
Scum thickness:n1a
Distance from top of scum to top of outlet tee or baffle:n/a
Distance from bottom of scum to bottom of outlet tee or baffle:n1a
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
Na
(revised 11/15195)
6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 660 Pitcher Way Hyannis
Owner: Gloria Delcore:22 Gladstone SL Evert Ma
Date of Inspection:3110197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Na
Material of construction:_concrete_metal_FRP_other(explain)
Dimensions: Na
Capacity: n1a gallons
Design flow: nla gallons/day
Alarm level: nla
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Na
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: Na
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box etc.)
Na
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
Na
(revised 11115195)
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 660 Pitcher Way Hyannis
Owner: Gloria Delcore:22 Gladstone St.Evert Ma.
Date of inspection:3110197
SOIL ABSORPTION SYSTEM(SAS):X
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to.be present,explain:
n1a
Type:
leaching pits,number: 1,000 gallon leach pit
leaching chambers,number:n1a
leaching galleries,number: n1a
leaching trenches,number, length: Iva
leaching fields,number,dimensions:n/a
overflow cesspool,number:n1a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
The overflow is structurally sound and functioning properly.It was empty at the time of the inspection.Pit has had Tin it.
CESSPOOLS:_
(locate on site plan)
Number and configuration: n1a
Depth-top of liquid to inlet invert: nfa
Depth of solids layer: n1a
Depth of scum layer: n1a
Dimensions of cesspool: n1a
Materials of construction: n1a
Indication of groundwater: nfa
inflow(cesspool must be pumped as part of inspection)
nla
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
n1a
PRIVY:_
(locate on site plan)
Materials of construction: n1a Dimensions: n1a
Depth of solids: n1a
Comments:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
nfa
(revised 11115195)
8
�• 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 660 Pitcher Way Hyannis .
Owner: Gloria Delcore:22 Gladstone St Evert Ma.
Date of Inspection:3110197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
6 Ec) I. •n
AP
(D
�p )l
0V 5a
DEPTH TO GROUNDWATER
Depth to groundwater:12 feet
method of determination or approximation:
USGS Maps and Charts
(revised 11115195)
9