HomeMy WebLinkAbout0937 PITCHER'S WAY - Health 137'PITCHER'S WAY
Hyannis .
:=A ="272 �f 142 t �.
Commonwealth of Massachusetts —/SL
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is required for eve Hyannis MA 02601 June 16, 2014
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 A. General Information
filling out forms \\I
on the computer, `..J\
use only the tab 1. Inspector: U(U
key to move your
cursor-do not David D. Coughanowr, IRS
use the return Name of Inspector
key.
Eco-Tech Environmental
46 Company Name
P.O. Box 1265
Company Address
r West Chatham MA 02669
Cityrrown State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification
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
SJune 16, 2014
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 is a shared system or M1 .
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.
n. a
""This report only describes conditions at the time of inspection and under the conditions of use Y:
at that time.This inspection does not address how the system will perform in the future under '
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspeffnr Subsurface Sewage Disposal System•Page 1 of 17 i
ft
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is required for every Hyannis MA 02601 June 16, 2014
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes: ,
i
® 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:
Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer
Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5, or
specified by local regulations. The scope of this inspection is limited to health and environmental
compliance and the septic system has been evaluated according to the conditions observed on the
day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing
determination.
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 201years old is available.
❑ Y ❑ N ❑ ND (Explain below):
A
t5ins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
937 Pitcher's Way- Assessor's Ma 272 Parcel 142
P
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is required for every Hyannis MA 02601 June 16, 2014
page. CitylTown 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(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken.pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
l5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Officiial Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°^M 937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant c/o Teresa A. Wright
Owner Owner's Name
information is required for every Hyannis MA 02601 June 16, 2014
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® 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
El ® 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 '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is required for every Hyannis MA 02601 June 16, 2014
page. City/Town 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is required for every Hyannis MA 02601 June 16, 2014
page. City/Town 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): • 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
��M a 937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is required for every Hyannis MA 02601 June 16, 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
System was installed by John Aalto in 1981.
Number of current residents: 0
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)): 29 gpd
Detail:
2012: 1496 gallons 2013: 19,449 gallons
Sump pump? ❑ Yes ® No
Last date of occupancy: 2 months ago
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:
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is required for every Hyannis MA 02601 June 16, 2014
page. City/Town 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: owner
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is required for every Hyannis MA 02601 June 16, 2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
32+ years. Certificate of Compliance for original system issued 9/8/1981 (Permit#81-10).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
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.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 1
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: 8.5 x 5 x 6-1000 gallon
Sludge depth: 6 in
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
Information Is required for every Hyannis MA 02601 June 16, 2014
page. City/Town 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 in
Scum thickness 1 in
Distance from top of scum to top of outlet tee or baffle 9 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? Design plan
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pumping is not required at this time. Maintenance pumping is recommended every 2-4 years with
year round occupation. Tank and tees appear structurally sound and functioning as intended. No
evidence of leakage in or out was observed.
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
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ,...... a 937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is required for every Hyannis MA 02601 June 16, 2014
page. Cityrrown 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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
ugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is required for every Hyannis MA 02601 June 16, 2014
page. Cityfrown 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 at 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.):
Camera inspection showed no adverse conditions.
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:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
1 ^"
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is required for every Hyannis MA 02601 June 16, 2014
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leachingtrenches number, length:
9
❑ 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.):
Soils above leaching pit appear unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. A hole was dug into leaching pit
stone and no effluent contact staining was observed in the stone or overlying soils. No standing
effluent was observed to a depth of 2 feet below the peastone layer.
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is required for every Hyannis MA 02601 June 16, 2014
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.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is Hyannis MA 02601 June 16, 2014
required for every y
page. Cltyrrown 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
L 0OCA VONS
-OF SEPTIC COMPONENTS
-DISTANCES IN DECIMAL FEET
LEACH A 8
PIT
1 24 24
►000 GALLON 2 15 43
DISTRIBUTION BOX 2❑ ® SEPTIC:TANK 3 31 67
A B
EXISTING
DWELLING LNG THIS SKETCH IS
BEST .VIEWED IN
0 937
COLOR FORMAT
a 3
e
e
o
Q
a . .
508 364-0894
p§TONERS WAY
l`P
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System:Page 15 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
�M 937 Pitcher's Way- Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is
required for every Hyannis MA 02601 June 16,�2014
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 25+
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: 1/9/1981
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:
Barnstable GIS Department
You must describe how you established the high ground water.elevation:
Approved design plan on file with the Board of Health shows bottom of system to be 1.5 feet above
the bottom of a witnessed test pit in which no groundwater was encountered. Town of Barnstable GIS
Department records indicate that the property is over 25 feet above groundwater table.
�I
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 937 Pitcher's Way Assessor's Map 272 Parcel 142
Property Address
Florence M. Grant, c/o Teresa A. Wright
Owner Owner's Name
information is required for every Hyannis MA 02601 June 16, 2014
page. CltylTown 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
GEOHYDROLOGICAL PROFILE
NOT TO SCALE
z
Q
a
PRECAST
LEACH W
]C14
PIT
BOTTOM:OF CL
LEACHING
PER DESIGN ui
PLAN
'LEACHING IS
ABOVE HIGH
GROUNDWATER
41
U�
GROUNDWATER No
ELEVATION GROUNDWATER
PER GIS MAPS-
ENCOUNTERED
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601 April 25, 2012
required for every y p
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 t-a --i
filling out forms A. General Information
on the computer,
use only the tab
key to move your 1. Inspector: t ,
cursor-do not r w
use the return David D. Coughanowr, R.S.
key. Name of Inspector
Eco-Tech Environmental
Company Name
43 Triangle Circle
Company Address a
Sandwich MA 02563
City/Town State Zip Code
508 364-0894 1328
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
ja0k �.
S April 25, 2012
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 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.
Uued 5/� z�f�
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
}7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601
required for every y April 25, 2012
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer
Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The
scope of this inspection is limited to health and environmental compliance and the septic system has
been evaluated according to the conditions observed on the day it was inspected. No estimate or
guarantee of system longevity is made or implied by a passing determination.
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):
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601 Aril 25 2012
required for every y p
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M , 937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601 Aril 25, 2012
required for every y p
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® 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 1/2 day flow
l5ins•11/10 Title 5 Official Inspection Form: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
937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601 Aril 25, 2012
required for every y p
page. City/Town 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601 April 25 2012
required for every y P
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® 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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd
t5ins•11/10 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
MURI
;M 937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601
required for every y April 25, 2012
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
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 d 41 gpd
9 ( Y 9 (gpd)):
Detail:
2010, 2011
Sump pump? ❑ Yes ® No
Last date of occupancy: 1 year ago
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:
l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 937 Pitchers Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601 Aril 25 2012
required for every Y p
page. City/Town 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 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601 Aril 25 2012
required for every y p
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Age: 24+ years. Certificate of Compliance issued 9/8/87. (permit#81-10).
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
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.):
Sewer line appears structurally sound with no evidence of leakage or backup into dwelling.
Septic Tank(locate on site plan):
Depth below grade: 1
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: 8.5 x 5 x 6 - 1000 gallon tank
Sludge depth: 3 in
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
nH
937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601
required for every Y April25, 2012
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 31 in
Scum thickness none
Distance from top of scum to top of outlet tee or baffle 10 in
Distance from bottom of scum to bottom of outlet tee or baffle 14 in
How were dimensions determined? design plan
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level at outlet invert. Pumping not required at this time, but maintenance pumping is
recommended within and every 2 years. Tank and tees appear structurally sound and functioning as
intended. No evidence of leakage in or out was observed.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601 April 25, 2012
required for every y p
page. City/Town 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
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601 Aril 25, 2012
required for every y P
page. Cityrrown 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 at 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.):
D-Box appears structurally sound and functioning as intended. No evidence of leakage in or out was
observed. Some solids in sump.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601 Aril 25, 2012
required for every y P
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
1
❑ 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.):
Soils above leaching pit appear unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into
leaching pit stone and no effluent contact staining was observed in the stone or overlying soils. No
standing effluent was observed to a depth of 3 feet below the top of the leach pit.
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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601 April 25, 2012
required for every Y -P
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachdsetts-
�f Tithe 5 Official Inspectian FOrnn
Subsurface Sewage:Disposal System Forrrr=Not;for Voluntary Assessments
937 Pitcher's VLVay
Property Address:
Florence M.Grant
Owner Owners Name
inforrnation is
requlred;forevery Hyannis MA 02601 Aprll 25,; 2012
page._ City7Lown State; Zip Code; Date of Inspection
.. Sys."tem.inforMation (cont)
Sketch Of-Sewage Disposal System' Provide a view of the sewage:,dsPo mincluding ties to
at least two permanent reference landmarks.or,benchmarks. Locate all;wells within 1'00 feet:-Locate
where public oyster supply enters tie building. Check ohb,of the.boxes below
. hand sketch in'the area;below
drawing attached,.separately
If
t5ins•.11110 Tit10 5 6feiicia'l Inspection.Form:Subsur-face'Sewago Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°^M 937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601 Aril 25, 2012
required for every y p
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells .
Estimated depth to high ground water: 25+
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: 1/9/81
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:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Approved design plan on file with the Board of Health shows bottom of system to be 1.5 feet above
the bottom of a witnessed test pit in which no water was encountered
Town of Barnstable GIS Department records indicate that the property is over 25 feet above
groundwater table.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 937 Pitcher's Way
Property Address
Florence M. Grant
Owner Owner's Name
information is Hyannis MA 02601 Aril 25, 2012
required for every y P
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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
LO, CAT ION 4�- SEWAGE. PERMIT NO.
VILLAGE
1NSTA LLER'S NAME i ADDRESS `
R: U I`L D E R OR OWNER
DA.T E PERMIT 1SS'U E.D
DAT" E C0MfLIA4NCE ISSUlD
No.------ ---..... - Fmc..... .....�)..............
THE COMMONWEALTH OF MASSACHUSETTS
E�� /OAR® OF HEALTH V /' ��a �1
...----.....W1W .......0F........, �� �Y--al�.L� ---------------------•-------•
App iratiou for Uiipatia1 Work.5 Tomitrurtion ramit
Application is hereby made for a Permit to Construct (() or Repair ( ) an Individual Sewage Disposal
System at
A ...cle ............ .....................e�71..... /......................................................
t�-. ... al it ... dres �`�=,37.......C.�.G�f Ll.. f�:\-Y_.1.� -.----.---
......... .. _._... .... ......................
kAt � . ......
. Address
Installer Address
dType of Building Size Lot4;:;M �_._•----Sq. feet
U Dwelling—No. of Bedrooms..............• -. _ _----..•_---___--.-Expansion Attic ( ) Garbage Grinder ( )
U
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ............................
- -- ------- -
Desi Flow......................f..5...._... _..gallons per person r day. Total dai flow__......... -
gn g P P P Y ����33'' ------------ ------•-----gallons.
WSeptic Tank—Liquid capacity � gallons Length-_-. -____ Width__..7.1�... Diameter................ Depth...�1f�._._
x Disposal Trench—No...�l✓�__. Width._.._�...,.Ti.... Total Length----------,f...... Total leaching area... .__ .___sq. ft.
Seepage Pit No----------/........ Diameter......1 .._h Depth below inlet..... Total leaching area - ..... ft.
Other Distribution box ( Dosing tank
'-' Percolation Test Results Performed by--------------��t�� ---?X.
....�..... Date....-1�� ...........__.
Test Pit No. 1....•c-�___.*Z.minutes per inch Depth of Test Pit___ _____ Depth to ground water_____ ..._..
Test Pit No. 2_.__�a..minutes per inch Depth of Test Pit...... ....... Depth to ground water....,��..___.
....... •----•---•----•--•....................••. •-••••.....--••-•......••--•.........................................................
Description of Soil C_ '....-a -J - �`= .........
.................tbaft'--e---------------------------
x
v �1e/?zz•---�-----�f� r� 1=
W ---------------------- -----------------------------------------•---------•-•-•------•............. ------------------------------------------------------•--•-••-••-•---•--•-••............----
UNature 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'T...i° 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued the board of be th
Sign ��/ ` `�' !_� �
Dat
Application Approved By....... �� _ 11
Application Disapproved for the following reasons:.....................................................................
.....................Date------........
Date
---------------------------
•-------------
-------------------------------•----------------
PermitNo......................................................... Issued.......................................................
i Date
No. ..���._....... _ FEs............... ........ ...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEA T
-------oF...... �� - . ...........................................
Appliratiou for Dispoii al Works Tomitrurtinn Frrutit
Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal
Systema ......................................................o .0 /
........... .................. ....... .-----------------------------......_...•.......--...........----•-
oc t'o -t�ddre s• � 3 t o
>! O ner Address
Installer Address
QType of Building Size Lot��1� ...........Sq. feet
Dwelling—No. of Bedrooms............3..........................Expansion Attic ( ) Garbage Grinder ( )
pa Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures ....................... -------- ---
W Design Flow_____________________�..-�.._.fi ._gallons per person p9/day. Total daily/flow____._.___ - ..gallons._______.____..__.____._
1x Septic Tank—Liquid capacity,/...__.___.gallons Length___-6_---------- Width................ Diameter................ Depth.._.._._........
Disposal Trench—No .1V 1-..._.. Width_...__.__;._.... Total Length----------I........ Total leaching area .......sq. ft.
Seepage Pit No..__._.__7._. .____ Diameter..___l�l__��. Depth below inlet._. -''__________.. Total leaching are Y' ._....sq. ft.
Z Other Distribution box (� Dosing tank 0 ) /e
`-' Percolation Test Results Performed b 61�f� "S ^ '� w A'� /d+��
Y Date......------•-••--......
Test Pit No. I...-"�- '- __minutes per inch Depth of Test Pit_____F�_. Depth to ground water..____._
f=I Test Pit No. 2___�_".`...minutes per inch Depth of Test Pit.................... Depth to ground water---
'-----•........a __ _ ................. ...........................................................................................
P
O Description of Soil ��`� �1 0.... �"......-- . ----------------•---------•
x
U -------------�-- A�----- ....9.40.0.11t........................................................................................-------------------------------•-------
W ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------•--•--------------------•---
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 TTTL y g g p y 5 of the State Sanitary Code— The undersigned further agrees not to lace the'system stem in
operation until a Certificate of Compliance has been issued• .y the board of iealth ,may
_ �. /_!I_Sign `4
`Dave+
Application Approved BY. / --- ':....._... _...1 --- ------f
tr;/� Date
Application Disapproved for the following reasons: ------------------------------------------•--------------------------...........---
............••..•-••-•-•----•----...-•••••--••••--•---•--•-------•-•-•-•-----•---•-----•••---••-••-•••......-•-•--•-••-••-••----••-•---------••................................•---- --•--••-•---..
Date
PermitNo......................................................... Issued_.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(Irrtifiratr of Tomptianrr
THI 1 TO CERTI,F , That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
.bY-•--•--....a.b jq. A .��--- ------------------------------------•--------------•------:-----------................:... --------. ----------
``�� nst ller
has been installed in accordance with the provisions of T `��f� T. e State Sanitary C.de as de rib in the
application for Disposal Works Construction Permit Nor.. _________________ dated-_-)7. . :�. ..�.........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY.
,V�,���._....-DATE............. Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.---.... .. /I�1............
.......... FEE........................
i n a1 nr . Tn Otrur#ilan i
Permission is hereby granted.......... ------...--••..........
to Construct O or Repair ( ) an Znd'vi.du 1 Sewage D' osal S stem
�irs �y
at No..-.'*
o.. •--•--••••••••--••••--•-•---r _ .............................................................. .................................................................................
Street
.r G
as shown on the application for Disposal Works.Construction Per '�t' o......__,: __.: ted_.�.....%.."//
.........................
�''..., .. �. nC� --•-•--.. ._. .-. Board of Health---•- ---------------•---.
DATE...... ------------------
----------- ...............................................
FOR17 1255,; HOBBS & WARREN: INC.. PUBLISHERS
�. _ - - .x.
� /
'awn o Barnstable �-- )V
Regulatory Services Department
Public Health Division 200'
200 Main Street,Hyannis MA 02601
email: Bamstable.RentaLRegistration,@,town-bamstable.ma.us
e.ma.us
OFFICE. 509-862-4644
FAX: 508 790-6304 Thomas A.McKean,CHO
"PUCATION FOR , I AL RE,GLSTi RATION Date:' It
Fee:S90-00 Per Unit-Plus 525 for
each addle➢.unit on the same parcel
I,tiZ Property Location: 93 q P1�I C H E R13 (,k)tq y , • j )A 0j U i S jT tV O a G O r
�L UNIT# If Applicable,BUILDING#/
Assessor's Map and Parcel: a `7 a- 1`{-
So(d Total Number of Rental Units You Own At This Property(inel'mdin unity)
Owner's Name: FLO oe6-10 C` M . GRq,u i
►� '� ?ate of Burch
Telephone Numbers (Daytime)
(Home Phone) (Ce ar)
Owner's Address: (o R A F R1 O S. (�. E iu ru'S m A. O .(o(0 0
Mailing Address: (if different than
Owner"s Representative's Nam flf Applicable): /t ReLsy4 (•c)R���1
Address:
Telephone Number: K d 8- as( _ 018 1
Occu l antt's Name: A C c�e L A 0.F
Daytime Phone her: - Cellular —
Nfunmsber of edroomns: 3 Cheek One: Is this a single family dwelling unlit?
an ap ent bunilding,? or an accessory apartment? Private Drinking Wen? �
Do Your.Have ZoninngQBnildimg Division Approval for an accessory apartment?
Win there be any children under the age of six who will be occupying the rental unit?
(circle one) Yes brio
Was the dwelling constructed prior to 1 979? Yes
i cuiify that the inDfon �(;n`proavided above is true: /]
tlfispertidnsDone Annually. Applieantt!s.Slgna
Q-V►pplicaiton Fb=skRenta1R1 egi sriFlpbmFbrm w 25 fee May Z0012.dec �A�u� )I.®F-2
INfSTRt7Cfi I®Nf ON PAGP 2
FF. — �.00 ` -- TYPICAL SYSTEM PROFILE
A R E A PLAN FINISH GRADE=-5 0
FDN TOP NOT TO SCALEI
GRADE OVER PIT= —_/•off-'
SCALE : 1 ��= S/. G� FINISH GRADE OVER TANK= �/•G�C1 FINISH
L. 0 T4* l 4 P i 7-C NE-k S w�"Y, 2 1. 5-9 7 S. F
ri4ri •M rr�r+rw����w�riMlw�����•�••11w.��re�s.wlAwl��f _
/VO T 1 hJ Ti-- E bl4k IN 77-} 8 L 0 FL OC 0 i 11l � -
n/O CC�1�15 E'�2 _'� I'! n- k/ /N Y Q 1, Vj5L) �I .p�," P V C OR Q7, 67 O o - ' • ... • O
_ C. I . TEES 47,33 ' • ` ` °
VY /�/ Y7(/' T !-Ek / 7 f� � l TC i 47 4, `7�..�� a•o:. o o, Q. v • e o • • • e • i •
B M T
FLR 44,00` /Q GAL. 4 • 'q .2 r • • • o • • o 0 0 °
REINFORCED DIST- BOX ° • • °
CONCRETE -g TO BE INSTALLED ON ' • e . • • • ° ° °
A LEVEL STABLE BASE • • s • • • I • o ° • • o
o.
SEPTIC TANK
TO BE INSTALLED ON A i •
LEVEL STABLE BASE
�"- ' '' • . • . • • • • • . • �:
2 i/8 - I/2 WASHED PEASTONE ALL
r� Q7- �,c BRICK a MORTAR COURSES AS AROUND FREE OF IRONS FINES ' °_e • ° ° °
L ` REQUIRED TO BRING COVER TO GRADE AND DUST IN PLACE
� v t LEACHING PIT
u 1 rt 24 C.I . MANHOLE COVER a 3/4 TO 1 -1/2 WASHED CRUSHED
0 FRAME SEE DETAIL STONE ALL AROUND FREE OF BASE TO BE LEVEL
IRONS, FINES AND DUST IN
Q PLACE 'tSr" 1�'
S �9 0 „$�/ FOR FIN. GRADE
_ � �.,... 194. 17 SEE SYSTEM PROFILE SOIL AND PERCOLATION
t` �1 P,
, Q AST 4 _ I DATA
�S8'P7'/G — — —
Lr Q�#. o _ _ B — - - - - — _ -- _ P E R C. RATE : 1 M I N l I N.
!" Box,SE6f�►ki[.E 3 B,R _ _ �'°T
`+► Xl N (e 4 FOR INV. ELEV SEE
tV '-,e,� sresvc. r k,AAJ H 1�� In h V} INLET
° ° ° SYSTEM PROFILE •, TAKEN BY . C. D. SPOHR
44 R NS i 2 !°x �u F ISM tP LINE 0 „ — �6 ° ° .. •/L'1R. P/,I-,i. /= i AY �
s X �
\OPENINGS W/4-1;8 „� DATE :
BY. a >
°
OUTER DIA & I 3/4 ° _
r� • � W.4.-/< - 7 0 INSIDE DIA . • TEST ,PIT -GND ELEV, �f S
TOTAL ,
M s' 4 } • ' ° °° ° 0 0 0 o 3
AREA
97 S.F. `. :• " G
VL A4
OIL NO RVS T, L kVGf
OBE' ^9T4me
07- , ` . .... .... ..� _ D D o o a o COARSE �C3RGYYA
°
' /v 6 - o SANt� i
_ o 0
2-t 6 6 DIA . Z-
offEFFECTIVE DIA. BOT. PERC. HOLE
- ------- ---- ---- -- DOWN
LEACHING PIT - SECTION �i � � ' .,
i
NO SCALE DESIGN DATA : !
NOTE: DO NOT RUN HEAVY EQUIPMENT OVER SYSTEM N0. OF BEDROOMS j
A/'') DISPOSAL 6
LEACHING PIT NOTES: EST. TOTAL DAILY EFFLUENT 0-30 GALS. E
EL �vAT/r�n�5- ���� ou �•-' ��'��>�`i�•:f PLAN REF: I • CONC. TO BE 4000 P.S.1 a 28 DAYS . SEPTIC TANK � - GAL.
E'D Ge�'N7pr�`1�L/A/� dF L_O•T" � �lSScl.t�fE,�
2 . REINF W 6 " x 6 06 GA. W. W. M.
�rL . 2'6 - 0' !:'�G1ST-kY 3. 2 `AND 4 ' SECTIONS ARE AVAILABLE FOR
Off' VEV)S., Pl.�Al 1:100k: GREATER DEPTH REQUIREMENTS GENERAL NOTES
1 . ALL SYSTEM COMPONENTS SHALL BE INSTALLED IN
NOTE : ACCORDANCE WITH TITLE OF THE STATE SANITARY CODE
EXCAVATE TO ELEV. — OR LOWER AS DATED JULY 1, 1977 Bi ANY LOCAL RULES APPLICABLE.
REQUIRED TO REMOVE ALL LOAM AND CLAY CONTAINING 2. ANY CHANGE TO THIS PLAN MUST BE APPR'D. IN
MATERIAL BENEATH PIT. REPLACE EXCAVATED MATERIAL WRITING BY MR. CHARLES D. SPOHR.
WITH CLEAN,CLAY FREE GRAVEL, MECHANICALLY
COMPACTED IN PLACE. 3. WHEN CONSTRUCTION IS COMPLETED, PRIOR TO BACKFILLING,
SIDE AREA = 198 S. F. S. F./GAL -125 GALS NOTIFY THE ENGINEER AND BOARD OF HEALTH FOR INSPECTION.
4. FOUNDATION ELEV. MUST BE CHECKED WHEN COMPLETED.
BOTTOM AREA=�S. F.�—S. F./GAL GALS 5. THESE ELEVS. MUST NOT BE CHANGED WITHOUT WRITTENTOTAL AREA = Z - S. F. TOTAL g GALS APPROVAL BY CHARLES D. SPOHR,
LEGEND 6. FOUNDATION INSPECTION READ. WHEN EXCAVATED.
0W NE �A"E" BU I LDERS= AREA PLAN • + 50.0, EXIST. GROUND ELEV.
L,L�/� /� �.Lr.Y,AJ,A./ �J��.��. AP24-,,�,�/�ar FPO" /�407- P/—/ 50.0` FINISH GROUND ELEV."UNDERLINEC)"
BOX 37 OF Locilk-10 AM INVAIAIMS AllQ, 4750` PIPE INVERT. ELEV. REV. DATE DESCRIPTION
11C'Q1p C Si F &VI L.Uj5-P.; 57 C4,g-t . •
O TEST PIT LOCATION SEWAGE DISPOSAL SYSTEM
n FOR
SEPTIC TANK CLH {�Kr F L-
OT °' �; ( V I LV RS
cl
DISTRIBUTION BOX # 4 P 17 C E R'S WAY
4 " C. i . PIPE Jt^~Mass .... .. �..
<?•
hwlo-
HYA J N I S, MASS.
-ttttt+t -- 4"BIT. FIBER PIPE - TIGHT JOINTS �` s �' � D r •�-- ---.�
SPOHR
I '- /7 PROPERTY LINE �' . f N EsiGNED C.D SPOHR DATE /I DFc' 'P DRAwi N o No
o r � 7468 0 //
f =� I <A �\��r SiE - fit'` DRAWN : -- SCALE:aS SHOWN _
MA EC PCL LOT ]kU�SE MIN . CODE DISTANCE �; % ;;HECKE �P SD C D. S