HomeMy WebLinkAbout0050 QUAIL LANE - Health 50 QUAIL LANE, HYANNIS
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TOWN OF BARNSTABLE
LOCATION &1'10'/L 4-e,66C SEWAGE # � ;yr
VaEAGE �'.�,y�es i�'�f�'i ASSESSOR'S MAP&LOT
- NAME&PHONE NO. A
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) Oal T,5 (size)NO.OF BEDROOMS y
BUILDER OWNER '��• �• ►%. ���•��
PERMTTDATE: COMPLIANCE DATE: 7
Separation Distance Between the:
Maximum Adjusted Groundwater Table and-Bottom of Leaching Facility /3 � Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachin i ty Feet
Furnished by
i
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h /
i
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Commonwealth of Massachusetts
r
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is ��—�
required for HYANNIS. A' MA 4/10/10
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.. t' "
Important:
When filling out A. General Information
forms on the
computer,use 1. Inspector: �q
only the tab key "V
to move your. DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. DOUGLAS A BROWN INC
Company Name
r� P.O. BOX 145
Company Address
CENTERVILLE MA 02632
'6d1" City/Town State Zip Code
50&420-4534 S 14297
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: CD
«-...
® 'Passes ❑ Conditionally Passes El Fails
, f
%X1'aCD
--+r9
❑ Needs Further Evaluation by the Local Approving Authority a ( �
4/10/10
In is Signature Date •
The system inspector shall submit a copy of this inspection report to the Approving A hority(BOIR .
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.
t5ins•09M Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
1 III,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT required for MA 4/10/10,
every page. Cltyrrown 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:
SYSTEM IS IN PRETTY MUCH THE SAME CONDITION AS IT WAS WHEN I LAST INSPECTED IT
IN AUGUST OF 2007
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 0 N ❑ ND(Explain below):
t5ins-09N8 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
1 �
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"Y 50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
inormation is HYANNISPORT
requiredfor MA 4/10/10
every page. Cityrrown 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
15.3030)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 4/10l10
every 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 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
❑ N 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
t5ins•09/08 - Tine 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection_ p Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT required for MA 4/10/10 1
every page. Crty/Town State Zip Code
Date of Inspection j
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.. G
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 CM 15.304. The system owner should contact the appropriate
regional office of the Department.
f5ins•09108 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
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT required for MA 4/10/10
every 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
i
® ❑ 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)
® ElWas 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): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins-09/08 - Title 5 OfFicial.lnspection Form:Subsurface Sewage Disposal System-Page 6 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 4/10/10
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
ACCORDING TO AS-BUILT CARD SYSTEM CONSISTS OF A 1250 SEPTIC TANK D-BOX AND
TWO LEACH PITS
Number of current residents:
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 08/172-09/139
9 ( Y 9 (gP ))�
Detail:
Sump pump? ❑ Yes ❑ No
Last date of occu an CURRENT
P 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-09)08 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage`Disposal System Form-.Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 4/10/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: CURRENT
Date
Other(describe below):
General Information
Pumping Records:
Source of information: SCOTT FRANK PUMPED IN AUGUST OF 2007
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):
5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 4/10/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) I
Approximate age of all components, date installed(if.known) and source of information:
1977 OFF AS BUILT CARD
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 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.):
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: 1250
Sludge depth: TRACE
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 4/10/10
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? WOODEN POLE
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•09M _ 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
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is
required for HYANNISPORT MA
every page. Cdy/Town Date/10
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.):
TANK LOOKS CLEAN AT THIS TIME
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•09M Title 5 Official Inspection Form:Subsurface Sews a D s
B posal System•Page 11 of 17 -
f
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 4/10/10
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
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•09/08 True 5 Official Inspection.Form:Subsurface Sewage Disposal System•Page 12 of 17
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments.
pY 50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT required for MA 4/10/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching"chambers number:
❑ leaching galleries number:
❑ Teaching 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.):
PITS ARE BOTH PRETTY MUCH AT THE SAME LEVEL AND STILL HAVE @ 18" FROM THE
STAIN LINE TO PIPE INVERT "
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
rY 50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 4/10/10
every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
sY 50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 4/10/10
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r� 50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT required for MA 4/10/10
every page. CltyfTown 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: 13 FT
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:
INSPECTION REPORT DATED 3/14/98
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT required for MA
every page. Cltyf town Date of 0
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal posal System•Page 17 of 17
u
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
50 QUAIL LN
V —
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 8/21/07
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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.
�j
Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
TOWN OF BARNSTABLE
LOCATION SEWAGE # 7 S�
VILLAGE �`lf ri.?iis%.C% ASSESSOR'S MAP & LOT aS� 1V L Z
INSTALLER'S NAME&PHONE NO. A'O L,1e:--4CY
SEPTIC TANK CAPACITY /d,:5� G/�l
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS y
B•>)$HER OR OWNER 1z11f5. AWY C.
PERMITDATE: COMPLIANCE DATE: 7�of77
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and LeachingFacility (If an wells exist
ty Y •�
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachin ff ility) Feet
Furnished by ' 1;�
� �.
� - - -
1 �
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• v,
�,, �.
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W �._ _ _
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'1 0� y
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L TIO� SEWAGE PERMIT N0.
VI/ L/AGE
INS A LLE,R'S NAME & AD:DRESS
Bk4DER OR WNER
'7`
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED -7 -7
1
1'
Cam.
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�O OF..... ' .. ................ ...........
Appliration -fur Bhipmal Eorks Towitrurtion Vrrmft
Application is hereby'made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: p
stit _ _.. .v ��o P ---_----------------_----6/------��---•----------•--•--------------------
P Locayy,g�n�•Address -------- � or Lot Noy �•• ����s
_._._... ..-- -
Owner ® Address
Installer Address
d Type of Building Size Lot�.�/_ JAB ---Sq. feet
U Dwelling—No. of Bedrooms________.._ _________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building __________________________ No. of persons........ Showers ( ) — Cafeteria ( )
Q' Other fixtures ---------------- ---------
d -------- ----- ---•---------------------------•----
w Design Flow________________^®....................gallons per pet-son per day. Total daily flow.__.__._.._... _____..__.._-.gallons.
WSeptic Tank—Liquid capacity/_S�!@_gallons Length________________ Width---------------- Diameter------.--------- Depth.__.____:____---
x Disposal Trench—No_________________ Width_____ ...._.__ ---- Total Length.................... Total leaching area--------------------sq. ft.
� • Seepage Pit No._ .�.k_9-- Dt07 eter____________________ Depth below inlet-------------------- Total le, hu g tTea -----.._________sq. it.
Z Other Distribution box ( / ) (2Fi, Dosing tank ( ) =i1�. J I a`'/- J/° c }�1� .
Percolation Test Results Performed by.......................................................................... Date_____------------ -------
Test Pit No. 1----------------minutes per inch Depth of Test Pit--------:----------- Depth to ground water...___.___.-__.._-.__._-
(%, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------.-_.______--
R+' y I/------------ -------------------- ;r
Description of Soil - /d ?'�.---_.---l o _.__535'�L�.........
U 2•-� - /�-�-•moo at '�__-------- -------------- -
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 Article NI of the State Sanitary Code— The undersigned further agrees not to place the system in .
operation until a Certificate of Compliance has b t ued by t b r f health.
j Sig d-/ G✓ // = D
Date
fa
Application Approved By-------- ,..ram- - - L1,0 �`? ate!D
Date
Application Disapproved for the following reasons:............... ....................................
---•---------•--•-•-•---•--------------------•---------------•-----------•--__-_.--------------•------_..._.-_-__--------------------•- -----------------------------------------------------------------
Date
PermitNo........................................................ Issued.......................... .............................
Date
-
- - - --- - -- ------ ----- ---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL
Appliratiun -fur :41-4pniial Worko Toll' iurtinn Vamit
Application is hereby'made for a Permit to Construct ( ) .or Repair ( ) an Individual Sewage„Disposal
System at
-------------
1._s:.z - -...../ . W.+ a .............................a `----'-2....-------------- ----------------
Loe n-A�dddress o Lot N
/jl _t_ • •cs. c.�c ------- .....
caner Address
--- -- ,r...I(.I -•--------- ------------------,a
Installer Address
d Type of Building �,/ y Size Loth` /_ ___Sq. feet
U DwellingNo. of Bedrooms___-_-_.-- ________________________Ex Expansion Attic Garbage Grinder
— -•a-- P ( ) g ( )
'Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures ---------------------------------------------
Design F
low -------------------gallons per person per day. Total daily flow_____________ ___.__-__-- -gallons.
R� Septic T:.nk—Liquid capacity d Bgallons Length________________ Width-------- lliameter_:.__..-..__::. Depth--_-_____-_----
Disposal Trench—_1jo_________________ c dd4l K_____________ Total Length____-__-____._.-___ Total leaching area.... ft.
Seepage Pit No._ _ _. Dt eter........: ......... Depth below --------------------- Total Ie 11 g er -----------------sq. ft.
z Other Distribution box ( �) �,?A7,, Dosing tank ; ;
aPercolation Test Results ` Performed bY--=----------------------------------------------------................... Dater-=`-=-----------------------------------
Test Pit No. 1--------------__minutes per inch Depth of "rest Pit.._-___.__________- Depth to ground water---._______._-._..___-
rZq Test Pit No. 2................minutes per inch Depth of Test Pit._♦__-____.._____-___ Depth to ground water__._-______-__-.__.:.._
/ -f� !Y 7 r --------------•-------
D Description of Soil �� ."`�!'� d: } � `.2 eS'd.[ Cr
-_ __...._.. - --
_ " /, .......... 1 _eT�A1 !,----- ----- '
x _..: _ ••----------------•--------------------------------=-------
a:.
UNature of Repairs or Alterations—Answer when applicab ------------------------------------___-_-_-_-_-__---.___-._________----_-..___-___._-__._.
---------•---------------------•-------------------------•--•-------•-------------------------=-------------•--•--------------------------------••---------•-------------------------------------------
Agreement
The undersigned,.agrees to install the aforedescribed Individual Sewage Disposal System in'accordance with
the provisions of Article \I of the-State Sanitary Code— The undersigned further agrees not to place the system in
operation iintil''a Certificate of Compliance has b 1 ued by t b f health.
...
„ 31- ?7
Sigd- - --- ----- ---R -- - --------------------- -�-------- ..................
Date
Application Approved By_-______ `
i Date
t Application Disapproved for the following reasons: --------------------- ------•----------------- ..............................................
.........................•--••--•---------•------•---------••----. ----•-:-------------=-------------------------------------------•---•-------•---------------•---------•-----_----•---------.........
` Date
Permit No............................. ........................... Issued--` -------------------=--- _ 7...
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL H
.....' ....
s (WITIrrtifirntr of��f�umIllianrr
T 1 0 FY, That the Indiu•d I Sewa e Disposal System constructed ( �or Repaired ( )
by �6G- h '' ............ -• ..... - . ------ �y�-------------- ------
at--- -- _.. 1lts.�Ge t "" - ------ .. -----
has been installed in accordance with e provisions of ,kr�• ee I of The State Sanitar C9de a; descr bed in the
application for Disposal Works Construction Permit No.''l,%�_ ! __.___ dated .... ... ___-.! ___________________
=-=
THE ESSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
,i SYSTEM WILL FUNCTION SATISFACTORY.
p ��` w
------------------------------------
DATE........ y n 0 �= f Inspector �( .....It..........
THE' COMMONWEALTH OF MASSACHUSETTS
BOARD O HEA.LIT
No.......... ------ -`---- � FEE----:------ ::::
, r
�tspo rk� n trnrtion r it
Permission-.is hereby granted----- ------ -- _ ✓ y�c-Ostem
--- �--- .. _ __---------- ---------------..............
to Construct' or Rep ' .. ) an In 'duall��S��gage sposa
at No._4--*- rj .!".-�
as shown on the application for Disposal Works Consttrruction ti_ Dated... -_� .—.�....._....
rt �� Bo of �`� {
DATE .._
Board Health
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
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t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT required for MA 8/21/07
every page. Clty/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: -
ti
f l I General anormaon l� r
When filling out A '
forms on the, �S
computer,use L,���
.
only the tab key 1 Inspector:
to move your r r
cursor-do not DOUGLAS A BROWN
use the return Name of Inspector
key. D. A BROWN
Company Name
r� P.O. BOX 145
— Company Address �.
CENTERVILLE MA 02 32
City/Town State Zip Code
508-420-4534 S 14297
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 CM 16.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8/21/07
nspector' nature 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.
Title V Inspection Form.doc•08J06
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page t of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 8/21/07
every page. City/Town 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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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:
❑ 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
Title V Inspection Form.doc•Of)JOS Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 8/21/07
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ 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
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.
Title V Inspection Form.doc•08/06
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts II
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
r` 50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 8/21/07
every page. Cityfrown State Zip Code Date of Inspection
{
I
B. Certification (cunt.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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".
I
Method used to determine distance:
I
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
I{
3. Other:
I
i
D) System Failure Criteria Applicable to All Systems:
I
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
I
❑ ® 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 availablellvolume 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.
Title V Inspection Form.doc-08/06
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
I
Commonwealth of Massachusetts i
Title 5 Official Inspection For
m
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 8/21/07
every page. Citylr°vn State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems(cont.):
Yes No
❑ ® 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.]
E] ® The system is a cesspool serving a facility with a design flow of12000gpd-
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.
I
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
i
❑ ® 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
El ® 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 jupgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT required for MA -8/21/07 I
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
i
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
j
Yes No
I
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previou'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?
j
® ❑ 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 IC is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
i
I
l
Title V Inspection Fonn.doc•08108
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT MA required for 8/21/07
every page. City mown State Zip Code. Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
Number of current residents:
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 AVERAGE
( Y g (gpd)) 200GPD
Sump pump?
❑ Yes ® No I
Last date of occupancy: CURRENT
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:
Last date of occupancy/use:
Date i
Other(describe):
Title V Inspection Form.doc•08106
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°< 50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT required for MA 8/21/07
every page. Cdy/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ® Yes ❑ No
If yes,volume pumped: 1250
gallons
How was quantity pumped determined?
Reason for pumping: MAINTENANCE
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:
1977 OFF AS BUILT CARD
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Title V Inspection Fonn.doc•OWN
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
informationefire for
is HYANNISPORT
required for MA 8/21/07
every page. Cdyrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Building Sewer(locate on site plan):
Depth below grade: 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.):
Septic Tank(locate on site plan):
Depth below grade: 2
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: 1250 GALLONS
Sludge depth: 0
Distance from top of sludge to bottom of outlet tee or baffle 0
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle 0
Distance from bottom of scum to bottom of outlet tee or baffle 0
How were dimensions determined? PUMPED FOR INSPECTION
Title V Inspection Form.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is required for HYANNISPORT MA 8/21/07
every page. City/Town State Zip Code Date of Inspection j
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.): i
TANK PUMPED FOR INSPECTION
!
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑Other(explain):
1
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.):
!
i
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):
Title V Inspection Form.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
t
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 8/21/07
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank(cont.)
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
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Title V Inspection Form.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,
'( 50 QUAIL LN
Property Address
SAMPLE
Owner owner's Name
information is HYANNISPORT required for MA 8/21/07
every page. Clty/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
Type:
® leaching pits number: 2
❑ 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.):
BOTH PITS HAVE ABOUT 18" OF USABLE SPACE LEFT AT THIS TIME
Title V Inspection Form.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT required for MA 8/21/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
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.):
Title V Inspection Form.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT MA required for 8/21/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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.
4-
Title V Inspection Form.doc•0&06
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
50 QUAIL LN
Property Address
SAMPLE
Owner Owner's Name
information is HYANNISPORT
required for MA 8/21/07
every page. Ciiy/Town State Zip Code Date of-
inspection-D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to ground water: 13'
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: pate
❑ 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 mustdescribe how you established the high ground water elevation:
OFF PREVIOUS INSPECTION DATED 3/14/98
Title V Inspection Form.doc•ONG
-Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Y
y >
Town of Barnstable
��F1HE 1p�
y�P ti� Regulatory Services
snxxsrns Thomas F. Geiler, Director
9� ' 9 •�� 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".
r
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
- tr-� '-�1�--
i
TOWN OF BARNSTABLE �.
LOCATION ��� G'��G L.// SEWAGE# P7—/�S�
VILLAGE l�%f��°%�s/�'G''�/� ASSESSOR'S MAP & LOT a13� /Z L Z 11
I
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS y
I
RFJ$DER OR OWNER
I
PERMITDATE: COMPLIANCE DATE: 7�0 �77
Separation Distance Between the: I
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist — Feet
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet i
within 300 feet of leaching facility)
Furnished by
,I
� I
y \
1
4
--l'`3�3 ```• fi
GI9/?FlG,� t p
�S
1
� I
4. �
,
`
. ,
. `
l
/
CERTIFIED SEPTIC SYSTEM REPORT
LOCATION
�
50 QUAIL LANE
HYANNISPORT, MA 02647
MAP 288 PARCEL 219 LOT 26PREPARED FOR
`
^ .
'
SELLER� ����
MR. B.J MEZG!R
50 QUAIL LANE
HYANNISPORT, MA 02647
MR. CHARLES SAMPLE
800 FRONTAGE RD.
NORTHFIELD, IL 60093
Li Y
HILLIARD HILLER, OR.
P.O. BOX 250
| CENTERVILLE, MA 02632
508-778-1472
�
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON, MA 02108 617•292-�500
N
WILLIANI F WELD TRUDY CO\E
Governor
Secretar.
ARGEO PAUL CELLUCCI DAVID B STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: {!J Qri' 97G Address of Owner,
Date of Inspection: (If different)
Name of Inspector:
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: —
Mailing Address::
Telephone Number:
CERTIFICATION STATEMENT
I cenify that I have personally inspected the sewage disposal system at this address and that the information reported belo"• 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:
amasses
— Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature; �2�� Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 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 !, B, C, or D:
AI SYSTEM PASSES:
1/ I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
COMMENTS:
B) SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (anached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tans:
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.
I
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: htlp:/rwww.magnet.state.ma.us/oep
C) Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: l�/e- / -��✓/s f2% , /rsA
Owner: ,J,P. a,J, �i��64<
Date of Inspection: 31A-110!
Bj SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high tatic water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the
Board of Health). Describe observat ons:
broken pipe(s) air replaced
obstruction is re oved
distribution box i levelled 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 oard of Health):
broken pipe(s) a e replaced
obstruction is re oved
C]. FURTHER EVALUATION IS REQUIRED BY THE OARD OF HEALTH:
Conditions exist which require funher oval tion 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 EALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC H LTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 fe t of a surface water
Cesspool or privy is within 50 fe t of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOAR OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A NNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank an soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water sup ly.
The system has a septic tank an soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank an soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank a d soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unle s a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution rom that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. method use to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: C�l/✓�fG �i�/� fj�%y,�,v�, j�J
Owner: ^4. G- �G�•d'/(
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as pan of.this inspection..
✓ _ As built plans.have been.obtained and examined. Note if they are not available with N/A.
The,facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components, lwcluding the Soil Absorption System, have been located on the site.
_ 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.
The size and location of the Soil Absorption System on the site has been determined based on: I
The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
�✓ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) (15.:302(3)(b))
I�
(revised 04/25/97) Page 4 of 10
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: j�!
Owner: AX.
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents:
Garbage grinder (yes or no):�
Laundry connected to system (yes or no):
Seasonal use (yes or no):_,d&?
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no):�
Last date of occupancy;
COMMERCIAUIND STRIAL:
Type of establishme t:`
Design flow: gallons/day
Grease trap presen : (yes or no)_
Industrial Waste Iding Tank present: (yes or no)_
Non sanitary wast discharged to the Title 5 system: (yes or no)_
Water meter read ngs, if available:
Last date of occ panty:
OTHER: (Desc be)
Last date of oc upancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as pan of inspection: (yes or no)_O&
If yes, volume pumped: gallons
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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: /%)) Ake- "/ --47 7�-/Cif/
Sewage odors detected when arriving at the site: (yes or no)110
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: ,497o< ,.T �jl2t✓,C,1
Date of Inspection:
BUILDING SEWER: l
(Locate on site plan)
Depth below grade:_
Material of construction: _ st iron _ 40 PVC other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of oints; venting, evidence of leakage, etc.)
SEPTIC TANK:J,,�
(locate`on site plan)`
Depth below grade.,Q,v
Material of construction: Koncrete _metal Fiberglass _Polyethylene _other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:_k 9 7 y /�4 ,y
Sludge depth: 7;' f
Distance from top of sludge to bonom of outlet tee or baffler
Scum thickness:
r.
Distance from top of scum to top of outlet tee or baffle:
Distance from bonom of scum to bonom of outlet tee or baffle: /7 rj-
How dimensions were determined:
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.)
GREASE tn
(locate oIan)
Depth beade:
Material struction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensi
Scum thi :
Distancetop of scum to top of outlet tee or baffle:
Distanceonom of scum to bottom of outlet tee or baffle:
Date of 1ping:
Commen(recommn for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, ce of leakage, etc.)
(rovisod 04/25/97) P49. 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ;SLR
Owner: ^,Q %& U, 1.*,X
Date of Inspection:
TIGHT OR HOLDING ANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of constructi n: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working.order _ Yes; _ No
Date of previous umping:
Comments:
(condition of inl t tee, condition of alarm and float switches,
DISTRIBUTION BOX: !/
(locate on site plan)
ii
Depth of liquid level above outlet invert:_
Comments:
+s 4
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) Tl�L_ i�ox lrilns
.:�Iz,wzO T/t Jl/Gh ��✓T Gv.�IS �t'.Od/JG. A ft3r/ /�.�Gr, G�5��Gr�G S %IY��'
7"y GA L' h�,�Li®lit�G- ls�l�/� l/t� /,�iS� cTlviv 8+�� ��t•=,t:
PUMP CHAMBE :_
(locate on site pl n)
Pumps in worki g order: (Yes or No)
Alarms in work ng order (Yes or No)
Comments:
(note conditio of pump chamber, condition of pumps and appurtenances, etc.)
i
(revised 04/25/97) Page 7 of 10
J
V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: l/.9rlL C,..�i� J�`Yi9.�.��5.�-�7
Owner:
Date of Inspection: 3/ r
SOIL ABSORPTION SYSTEM (SAS):_✓
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:^
leaching galleries, number:.
leaching trenches, number,length:
leaching fields; number,, dimensions;
overflow cesspool, number: -
Alternative system: .
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure; level of ponding, condition of vegetation, etc.)
ep4lr '/i G007S AyLL .1�11e_,0 71_1z o -11141 l 41-.!P"S ��'l% fl. o --����'�G S
tvfJs ial Old- lsa rzf�
��'II!—.t'L! �/�.�S 4✓.C/�.0 QL'�G/�.�'D 11Gr�.t� !��/T/1 T/>.� ;O � .fox Sri :h'f�r
CESSPOOLS:
(locate on site plan)
Number and configu tion:
Depth-top of liquid t inlet invert:
Depth of solids layer _
Depth of scum layer
Dimensions of cessp ol:
Materials of constru ion:
Indication of ground ater:
inflow (ce spool must be pumped as part of inspection)
Comments:
(note condition of oil, signs of hydraulic failure, level of ponding, condition of vegetation,.etc.)
PRIVY: _
(locate on site pl )
Materials of cons union: Dimensions:
Depth of solids:
Comments:
(note condition f soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(zrviood 04/25/97) Page 8 of 10
�M
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ,mil/ /L
Owner: g, iT
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
\ I
'S1 f �•:
aJ l
d, I
dd5:
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION,(continued)
Property Address:
Owner: �/� ,(,��f. /Ljd�GC•t
Date of Inspection:
i
Depth to Groundwater &tFeet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observation of Site (Abuning property, observation hole, basement sump etc.)
Determine it from local conditions
,Check with local Board of:health
Check FEMA Maps
Check pumping records
Check local excavators, installers
✓Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. (Must be completed)
.s'�vr-�si�'�G.�' Gls s/��-s ?h,� ,t'c,�,r:-�l.�.v � �,�• ;��?� 7'�y�•
��!.E'��E� c:-�Tx1t %.Q��• ;�ivc �i-�3 �,�.-9�r��.v6 5`/,�s �/�,c'
"q7
(revised 04/25/97) Page 10 of 10
L�
CERTIFIED SEPTIC SYSTEM REPORT 1a. �
No
�ti
LOCATION r' I j 1,99,5 ;�
50 QUAIL LANE `
HYANNISPORT , MA 02647
MAP 288 PARCEL 219 LOT 26 S
PREPARED FOR
SELLER .
MRS . MARY G. PILICY
P .O . BOX 55
HYANNISPORT , MA 02647
BUYER
NONE AT THIS TIME
PREPARED BY
HILLIARD HILLER, JR.
P .O . BOX 250
CENTERVILLE, MA 02632
508-778-1472
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
William F.Weld
ciammor
Trudy Coxe
Secretary.EOEA
David B. Struhs
Comml»ioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: SO Q v.,f/L Address of Owner: SG
Date of Inspection: /D/ay it /o/dG (If different) psre e /Gl,� / 444
Name of Inspector: NjLGlffRo
Company Name, Address and Telephone Number: Pp Qox a,so
e—XA/rZ4(//Ze X /f 4o?IC
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:
t/Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails /
Inspector's Signature: - .�AG� � Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 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:
V I have not found any information which indicates that the system violates any of the failure criteria as defined 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 8/15/95)
One Winter Street • Boston,Massachusetts 02108 • FAX(611)556-1049 • ,Telephone(617)292-SM
i,Printed on Recycled Paper
1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: G�v�s'lL G/y/i/L h'Yi1,rJjijc/oi^T
Owner:
Date of Inspection:
B]SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or 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 i
distribution box is levelled 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 watei supply of tributary to a
surface water supply.
_ The s\,stem has a septic tank and soil absorption system and is within a Zone I 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 absgrption 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 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•
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 into facility or system component due to an overloaded or dogged 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.
(revised 8/25/95) 2
I�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: So G?u,4/L L ,v,E /X>"f iv6Po.QT
Owner: o07iQ,5, iy/¢R y 4 /G y
Date of Inspection:
DJ 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).
Number 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 I 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.
EJ LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 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: /I
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 8/25/95) 3
:f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: S,�P 4v/9/4- G.ff dX h'Yl3.,r1P' VA0AT
Owner: *.,o V
Date of Inspection:
I
Check if the following have been done:
Pumping information was requested of the owner, occupant, and Board of Health.
_ done of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
t�—As built plans have been obtained and examined. Note if they are not available with N/A.
At-The facility or dwelling was inspected for signs of sewage back-up.
Lo"The system does not receive non-sanitary or industrial waste flow _
✓The site was inspected for signs of breakout.
/ZAII system components,eluding the Soil Absorption System, have been located on the site.
r/fhe 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.
vThe size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
_The facility o,%ne. (and occupants, if different frcm owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8115195) 4
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: /'s RS. *17,<y G— /&L/C Y
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: gallons
Number of bedrooms: 41
Number of current residents: D
Garbage grinder(yes or no): tA10
Laundry connected to system (yes or no):_z'e_S
Seasonal use (yes or no):.M?
Water meter readings, if available: fl4-T-4l9e,,L
Last date of occupancy:
COMMERCIAUINDUSTRIAL:
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
,vv Rf4aw'p Xmw
System pumped as part of inspection: (yes or no)_xoW
If yes, volume pumped £allons
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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
Sewage odors detected when arriving at the site: (yes or no)
(revised 8/15/95) S
;j
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: vU QvA/L ��� f/YfJ,r/•r�iS��.�%
Owner: o 7RS fi/eY co
Date of Inspection: /olj y e /-V/X/SC
SEPTIC TANK: 4-1
(locate on site plan)
Depth below grade: G!,v 1.,,X T .7 z y o'er
Material of construction: concrete _metal _FRP—other(explain)
Dimensions: lo'a'x S V'* l oDJ yV'I OX-L40
Sludge depth: Y" '
Distance from top of sludge to bottom of outlet tee or baffle: o? /�
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: _
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.) Two ¢ TlGS LoO`Lo lst�O A�co.�i.�YL.v/� A��`�' o'y
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom r`t «um t- bottom of outlet tee or baffle:
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.)
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: S� 6?44,¢/L 4-fvL h'Yf/lie--'l5 W
Owner: ^v"r5• olto-,ley 4
Date of Inspection:
TIGHT OR HOLDING TANK:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete_metal _FRP--other(explain)
Dimensions:
Capacity: Gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert=. �—
Comments:
(note if level and d:stributicn is equ:!, cviderce of so!id, carryover, evidence of leakage into or out of box, etc.) .0 !�X
L�LI�D Ga�D. dL/� SoL✓�s !y
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.)
(revised 8115195) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: _,Q9 QvAIG 4A6.0
Owner: Iifil> :S. .4f^e y G: y
Date of Inspection: A91d y 6 lyl;S—�S
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool,.number:
condition of soil signs of hydraulic failure level of ondin condition of ve etation,etc.) 017-- 4i0S
Comments: (note co g y P g� g �
e/wi'44� Ax/O corllS Boxy S�9,vD o.v L�7To� iPBcos�.�i� iP��SE�s /
CESSPOOLS: _
(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 (cesspool must be pumped as part of inspection)
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.)
(revised 8/15/90 8
f
r
y
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: QvAI z- LA S ,4T
Owner: iyiPS, *CRY �. oOIua Y
Date of Inspection: /p)/,g
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within tt)o'
I '
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DEPTH TO GROUNDWATER
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method of determination or approximation: RMAW- 64f G/S 5h'o0,5 7 Ye To 194e
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LOCATION:
REVISIONS: PROFESSIONAL BUILDING DE516N
O Prelimin.vyPloorPlans9/10/1 O COMMERCIAL•RESIDENTIAL 50 G�'UAiI Lane
�eviaed Plwn•,I O/1 B/I O cape cod•Ma55aGh115ett5
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Profeagional Building Designer
Any dlearepenues,errors a—romisdons
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A m PROPE5BIONALBUILDINBDE516N LOCATION:
REVISIONS:
0 Preliminary Floor Plaoea/10/10 GOMMER6IAL•REEIDEMTIAL c7O G�Uail Lane
F—i—I Plan 10/16/10 Gape Cod•Massachusetts
Preliminary Gone#ruNion Plans I I/1/1 0 &1draCVste•costa Rlea Hyan n i d por-h,MA
Engineered GorklYulh ion Plan, I IH/10 cepecodoksadeslgrtcom•uww.ksadeslgrtrgm
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D REVISIONS: PROFE55iONALBUILDIN&DESIGN
3 Prefmina yPloa pnna9/%O/l0 lOMMERGIAL•RE5IDENTIAL 50 e?UAil Lane
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become the re.pensiblllty of the
building contractor.
N (� Gopyf1gM oao 10 by KSA deslAn
m these lansare rotectedunder Federal ENGINEERED BY:
= A p p PI®19 # 18� PROJECT: -enovakions and?kcldikions for:
y. Copyright Laws.the orlglnai uct one
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one home using Chls plan.Modification or
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i, K5A design=
LOCATION:
REVISIONS: PROFESSIONAL BUILDING PE516N
O p Prehminwry Floor Pl.—q/90/10 GOMMERGIAL•RESIDENTIAL 50& UA Lane
�eoi>ed Plwn.,1 0/I D/1 0 Cape Cod•Mas6adhuaetta
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_ � Professional Binding De�gner
Aay diacrepandes of ean-...Von.
/// In the notes,dim enaions,and/or
drawinga contained on these documen to
`• � shall be brought to the attention of
the Pevgner prior to the commencement
g of tonetrucMan.F oceedinglath
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discrepandes,errors anvor omissons
/ become the responsibliltg of the
bulding contractor.
N (� C~43ht C3010 IN K®A design us
= e These sans are rotected under Federal ENGINEERED BY:
M j CopyrigMLBwsrheorlginelpurcheserofthis
PI�>9# 1 8�`fi PROJECT: �enovakions anti fticldil'ions for:
m plan is authorized to construct one and only
f�. z y One home using this plan.Modification Or
s reuse is prohibited without express written �AM �AX
permission of the Designer. lo
31
M t K5A design=
LOCATION:
REVISIONS: PROFESSIONAL BUILDING DESIGN
r+ F—limiaary Floor PI.--)/Oo/10 COMMERCIAL•RE51DENTIAL 50 6?U4il Lane
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draWnys contained on cheae documents
T 6na11 be troagnt Lo fAe at[Cntlan of
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do,=[esthe acceptance
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LOCATION:
REV1510N5: PROFESSIONAL BUILDIN&DE516N
O PrellmmnryPloorPlnna9 GOMMERGIAL•RESIDENTIAL 50 G'Uail Lane
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drawings con usht on Leese nti-its
shall be brought to the cemmelcn of
tee Designerpriorn.the commencement
1\ of c tlen ctl t Proceeeing pt
rnnstraf t' eonan[utes[ne acceptance
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bNldtng contractor.
P S11 tl eopyrlghto]otoby KSAdeelgn..: ENGINEERED BY:
m A These plans-aprotectedunderFederal Pj�P9 # j 8�� PROJECT: j=enovAkions and f�.dA-hons for:
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CONSISTS OF:
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/ PARCEL A (UNREGISTERED)
LOT 38A 131 .S. F. t 4'
PLAN BOOK 111 PAGE 93 0.00+ Acres t I
LOTS 45A & 46A BALANCE 98LLOT 2s
PLAN BOOK 84 PAGE 69 (REGISTERED)
43,538 S. F. t
�ECORp, 0.99+ Acres n/f JOHN F
& JUDITH R. 1:
TOTAL: TAYLOR NOB HILL
43,669 S. F. t
1.00 Acres t r
shape factor = 17.89 LOTS 42—A:
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124.35 10 T 3 B
C3 320.00 22'15 55 - . .
04'38 38
C4 320.00 25.94 CONSISTS OF:
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CS 50.00 80.84 8929 22 LOT 36 (REGISTERED) l
C7 1 9.83 OS37 49
00.00 1,848 S.' F. MARBLE 5B/DH FD
80.74 34'48 00 0.04 Acres r
ro 30.00 30.75 5843 49 CB/DH FD HELD
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