HomeMy WebLinkAbout0072 SAINT JOHN STREET - Health 72 Saint John Street
Hyannis
A=291-036-001
TOWN OF EARNSTABLE
LOCAII'loN ,7777777
sEWAGE
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Commonwealth of Massachusetts
�+ Title 5 Official , Inspection. Form M
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Saint John St `R
Property Address
Bobby Nunes
Owner Owner's Name
information is Hyannis = MA 02601 1-15-18. �
required for every H—Y
page. Cityrrown -• F " State Zip Code Date of Inspection j
:4
Inspection results must be submitted on this form. Ins;ection forms may Ynot be altered in an �'.
p p Y Y
way. Please see completeness checklist at the end of the form. F
A. General Information
1. Inspector: ,
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services . -.
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
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 16.600).The system: l
® :Passes ;,f- ❑, Conditionally Passes -. ❑ Fails
r ? ❑ Needs Further Evalua ' by the Local Approving Authority
1-15-18
Inspector's Signature Date
The system inspector shall submit a copy'of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original 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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R' N Subsurface Sewage Disposal System Form,-:Not for Voluntary Assessments
a%
72 Saint John St
Property Address
Bobby Nunes
Owner Owner's Name
information is required for every Hyannis MA 02601 1-15-18
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:
® 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 good working order with no sign of failure.
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts -
1a=1 Title 5 Official Inspection Form
'"'l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Saint John St
Property Address
Bobby Nunes °
Owner Owner's Name
information is Hyannis MA 02601 1-15-18,
required for every y - - -
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with`approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
` ❑ "obstruction is removed '❑ Y ,❑ 'N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Yr ❑ 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
t5ins.doc-rev.'6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
�a=1 Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Saint John St
Property Address
Bobby Nunes
Owner Owner's Name
information is required for every y H annis MA 02601 1-15-18
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: I - ..
❑ 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 '/2 day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
I�
Commonwealth of Massachusetts
7 f Title 5 Official Inspection form
MI Subsurface.Sewage Disposal System Form,-Not for Voluntary Assessments ,a
c�
72 Saint John St
Property Address
Bobby Nunes -
Owner Owner's Name
information is Hyannis t `' MA 02601 1-15-18
required for every H y '
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.
C
" ' ❑ ® Any portion of a cesspool`or,privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool orpnvy 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.].
❑ ® t 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
E] ' ®J criteria exist as described in 310 CMR 15.303,therefore the system fails. The
•r • •. - system owner should contact the Board of Health to determine what will be
1 e -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 16,000 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
�a=1 Title 5 Official- Inspection Form
l' -i Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments,
72 Saint John St
Property Address
Bobby Nunes
.Owner Owner's Name
information is Hyannis MA 02601 1-15-18
required for every
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
El ® 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 breakout?
Z , ❑, Were all system components, excluding the SAS, located on site?
®' ' k° ❑ 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
w ® ❑ information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
t , been determined based on: r
® ❑ Existing information.For example, a plan at the Board of Health.
❑: Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
{ Commonwealth of Massachusetts
Title 5 Official Inspection Form
�1� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Saint John St
Property Address
Bobby Nunes
Owner Owner's Name A
information is required for every Hyannis MA 02601 1-15-18 .
page. City/Town State Zip Code Date of Inspection
D. System Information 1 t
Description:
Number of current residents: 3
Does residence have a garbage grinder?. ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
r., Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): i
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 1-2018Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based,on 310 CMR 15.203)-
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins,doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
, Commonwealth of Massachusetts
�a Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
72 Saint John St
Property Address
Bobby Nunes
Owner Owner's Name
information is
required for every Hyannis- MA 02601 1-15-18
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: '
F
p 9
Source of information: N/A
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 t
❑ 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.doc-rev.6/16 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
t_;!✓ 72 Saint John St
Property Address
Bobby Nunes
Owner Owner's Name
information is required for every Hyannis MA 02601 1-15-18
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:
1995
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 16"feet
Material of construction: a�
® 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.):
Good condition.
Septic Tank(locate on site plan):
8'r
Depth below grade: feet'
Material of construction: :
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
12"
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts u
Title 5 Official Inspection Form
:�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r.
p_s�' 72 Saint John St -
t l��
Property Address
Bobby Nunes
Owner Owner's Name
information is
required for every Hyannis MA 02601 1-15-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.) Y
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? Tape
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 is in good condition with baffles installed and no sign,of leakage. Recommend pumping for
solids.
F .
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts F
a= f Title 5 Official Inspection Form
I
' iq Subsurface Sewage Disposal System Form Not for Voluntary Assessments
aF'
72 Saint John St `
Property Address
Bobby Nunes
Owner Owner's Name
information is ,
required for every Hyannis` l MA 02601 1-15-18
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
W
Commonwealth of Massachusetts
�a=1 Title 5 Official Inspection Form
,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a`
72 Saint John St
Property Address
Bobby Nunes
Owner Owner's Name
information is required for every Hyannis MA 02601 1-15-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from trenches.
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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
.1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.�, 72 Saint John St _
Property Address
Bobby Nunes
Owner Owner's Name ,
information is Hyannis MA 02601 1-15-18
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
® leaching trenches number, length: 2-30'x2'x2'
❑ 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 pondingi damp soil, condition of
vegetation, etc.): 1.
Leach trenches video inspected with no sign of back-up into lines or surrounding stone.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
I
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts _
�a=1 Title 5 Official Inspection Form
-'�-i Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments
72 Saint John St
Property Address
Bobby Nunes
Owner Owner's Name
information is H annis MA 02601 1-15-18
required for every y
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.):
b t
r
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
a f Title 5 Official Inspection Form
' . 1� Subsurface Sewage Disposal System Form Not for Voluntary Assessments
72 Saint John St
Property Address
Bobby Nunes +
Owner Owner's Name
information is required for every Hyannis MA 02601 1-15-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) F
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
,
Jill
low-
low
F!:
r
a
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts e
as Title 5 Official_ Inspection Form
f,
' 1-1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
72 Saint John St
Property Address ,
Bobby Nunes '
Owner Owner's Name
information is Hyannis MA 02601 1-15-18
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) a.
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
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:
USGS and town maps show groundwater at greater than 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
:ill f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
4�_Jai 72 Saint John St
Property Address — — -
Bobby Nunes
Owner Owner's Name
information is required for every Hyannis MA 02601 1-15-18
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.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
• TOWN OF BARNSTABLE
LOCATION ,r7 7 J G N 6-� SEWAGE # 9--) J �
ASSESSOR'S MAP&�LOT7c/���
INSTALLER'S NAME&PHONE NO � -72F O67J
SEPTIC TANK CAPACITY 15;5'i STi�A _ &6 0
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS BUILDER OR OWNER r�L �-VI
r.5 y �D
PERMIT DATE: 6%�COMPLIANCE DATE:
Separation Distance Between the:
7"
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) N�ln�� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leachi g cili Ivy�� Feet
Furnished by
. o
o � �
V a �
ua
No. Sr. Fee do,
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for Digonl *pgtem Con!5truction Permit
Application is hereby made for a Permit to Construct( )or Repair j,<n On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
�� �����N� �' - t�7�v�.,�s ���LDS �1°►e�Nv'o-t. .�,�v�-�..
Installer' �e,Address,and Teel.No. Designer's Name,Address and Tel.No.
ao
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow `�_75— gallons per day. Calculated daily flow --T340 gallons.
Plan Date &nj Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) v��s"1
le
K2 �
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued bv t ' f Health.
Signed---- Date le -03-95-
Application Approved by
Application Disapproved for the following reasons
r
Permit No. Date Issued
.. ' .4_ .(.r+'.-.., �,____. _. ;_' ,�� K . � l.. —'r1...'.-I'-1,,,Ny r.-..s ,,r .. F `f. � • -. .ty� . r''1 --...�� ....r—O E
^^fir r� [�/y �/,\( J} Fee
No.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS.
ZippYication for Digpogar *pgtem Con!9tr� t ott= f md
s
Application is hereby made for a Permit to Construct( )or Repair(Tan On-site Sewae Disposal System at:
Location Addressor Lot No. Owner's Name,Addles,s_qnd TelA No. "-'-4 r
a CDN t� ST"' tiwtiS c�. t-e5 {I' UNVot
Installer` v e/AyddrYess,and Tel.No.` Designer's Ne, d,re ani Tel.No.
Type of Building: All
Dwelling No. of Bedrooms Garbage Gr nd'er(�` )��i"F
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 'S gallons per day. Calculated daily flow gallons.
Plan Date 'I`I IA.. Number of sheets Revision Date i
Title
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) =Vti 9_1-Iu\
-2-
Date last inspected: /
Agreement: `
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system =.1
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation.until a Certifi-
cate of Compliance has been issued b f ealth. ..
Signed_ Date
Appli�fiaffl- pprove�y ��
Applicatii� pproved f r the- o�`lowing reasons
_
1 t 1
Permit No. k .r rDate Issued \
THE COMMONWEALTH OF MASSACHUSETTS
3u ,
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance -
j THIS IS TO CERTIFY that t -site Sewage Disposal System installed( )or repaired/replaced�on
by ��, � }.y _ c for C
as -7 _A 5 ,-S Try� S-r, - has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated `
Use of this system is conditioned on compliance with the provisions saJoyh below:
f
. No. I 713 tallo
Fee _
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC-HEALT� SIONY--BARN ABLE, MASSACHU ETTS
-.. i /- fix .fy_
Digpogat *pgtem Construction Permit
` Permission is hereby granted to
to construct( )repair( man On-site Sewage System to ated at �7 S� , 0�-v-j 5 T�
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within two years of the date below.Date: 2 Approved by ) 0 )-7
. 1
1
r'
i
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I �,eQb{�- 'j , hereby certify that the application for disposal works
construction permit signed by me dated /6 3 gJ , concerning the
property located at 7 c�ST>o�� �� [�"! `'�'s meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
17 SIG 1 / DATE:
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
i
G
a
c ,�
�i
Commonwealth of Massachusetts
,t Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
V7S�-
Property Address
Owner Owner's Name
information is A/ C,h k1�s 0�b Q
required for
every page. CitylTown State Zip Code Date of nsp tion
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see compl
eteness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer. use 1. Inspector: (/
only the tab key p
to move your Gj� D`,S?/
cursor-do not Name of Inspector r
use the return /� V/0 _ , L-�1y
key. L— Q
Company Name Q
/ doy /p� 0 0
reD
Company Address
p y .'La5
City/Town State Z Zip Code
Telephone NumbTr License Nu
D
B. Certification AUG 3 -0 REC'D
I certify that I have personally inspected the sewage disposal syst at this address and thi
he
information reported below is true, accurate and complete as of th 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
G1/ tz'" p
1,�4// iv
Inspector's ignature 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.
t5ins•09/08
Taie 5 Official Inspection Form:Subsurface sewage is00sal$/slem• age 1 of 17
ge
Commonwealth of Massachusetts
Titre 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
J D4Ih
Property Address % • /�� ��
Owner Owner's Name
information is
required for State Zip Code Date o In ection
every page. City/Town
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/ always complete all of Section D
A) System asses:
I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
---------------
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
is;ns•09/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
t Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
j JoHAI S�
V
Property Address T �$
Owner Owner's Name
information is q N 41 f / �a 6 0/
required for State Zip Code Date f In ection
every page. City/Town
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 ❑ NO (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ NO (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 ❑ NO (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ NO (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
t5ins•09r08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
Property Address T// 4
S
Owner Owner's Name b
information is
required for S Zip Code Date of ction
every page. Cityrrown
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, perfor
med at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ,�/ Discharge or ponding of effluent to the surface of the ground or surface waters
u due to an overloaded or clogged SAS or cesspool
❑ r-2/' 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 5" below invert or available volume is less
than '/2 day flow
t5.ns•09108 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
-T
Property Address
Owner Owner's Name (�a 6 D I b
information is a N I
required for State Zip Code Date of Inspection
9
every page. City/Town
B. Certification (cost.)
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
l� 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.
❑ Ly' 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.
❑ r-,/ 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•09108 Title 5 Official Inspection Form:Subsurface sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
ments
Subsurface Sewage Disposal System Form -Not for Voluntary Assess
- �
Property Address
Owner Owner's Name 0,2 Co O !f /O
information is q k10 rs
required forA State Zip Code Date f in pection
every page. city/Town
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
211�❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ [D"� 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): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms):
Sao
15ins•09r08 Title 5 Ofraat inspection Form:Subsurface sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form ents
Voluntary Assessments
I S ry
_ Subsurface Sewage Disposaste m Form -Not for y
Property Address %'
----------------------------
Owner Owner's Name G� o�60 !�c
information is N/ �_ /2
required for State Zip Code Date o Ins ection
every page. City/Town
D. System Information
Description: G�//o n f rc f a ^l./
go
a Y;e o c 4ef 30
a
Number of current residents:
Does residence have a garbage grinder? ❑ Yes
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes B No
Laundry system inspected? ❑ Yes 9 No
Seasonal use? ❑ Yes E? No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump?
❑ Yes No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow (seats/persons/sq.ft., etc,):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
15ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
f
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
U9
Property Address / /
Owner Owner's Name
information is required for rnJ - State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of S tem:
7
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•09r08 Titie 5 Offldal inspection Form Subsurface Sewage Disposal System-page 8 of 17
I
Commonwealth of Massachusetts
Title 5 official Inspection Form nt
Subsurface Sewage Disposal System Form -Not for Voluntary Assessme s
r
2d ST
Property Address T,
Owner Owner's Name j �� 0a j&01 [f 10
information is o,Yl h rJ
required for State Zip Code Date f In pection
every page. City/Town
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes
Building Sewer (locate on site plan): I?
Depth below grade: feet
Material onstruction:
cast iron ❑ 40 PVC ❑ other(explain):
D
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: feet
Material of struction:
oncrete ❑ 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
'5y �
Dimensions:
Sludge depth:
15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form nts
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
'ST TL) 4&-l1
Property Address
Owner owner's Name / ) �fJ� 0,41.of
information is
required for N ff State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness �l
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?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
U ►^'1 ✓i /!o T /7e2c'�� o f r1 t✓tip
I
G�s
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
urns-09f08 Title 5 Official inspection form:Subsurface Sewage Disposal System•Page 10 of 17
I
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
Property Address
Owner Owner's Name Qp2 601 V
information is h-41—r
required for State Zip Code Date of Inspec on
every page. City/Town
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
t5ms•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page t t of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.`
Property Address
Owner Owners Name /��7 �o�G d� �O
information is
required for c' rl State Zip Code Date of I spection
every page. City/Town
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
d
�10 Sa/t s
4a
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:
i5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
i
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
, Property Address ��•� �
Owner Owner's Name 0�l d
information is G H h� t
required for State Zip Code Date of ns action
every page. City/Town
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ aching galleries number:
leaching trenches number, lengto
❑ 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.):
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•OW8 TiUe 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
MOMMO Title 5 official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a
T °/t& s�
V
Property Address
Owner owner's Name
information is hlgrs Dat*1spection
required for State Zip Code
every page. City/Town
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.):
isms•09i08 Title 5 official Inspection Form:Subsurface Sewage oisposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form • Not for Voluntary Assessments
2c�
Property Address
Owner Owner's Name / '� T /V
information is A✓t — Date of Inspection
required for State Zip Code p
every page. City/Town
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
Check one of the boxesl wells belowwithin 100 feet. Locate
where p water supply enters the building.
hand-sketch in the area below
❑ drawing attached separately
I
3
d3- 3�
Title 5 offic,af inspection Form:Subsurface sewage Disposal System•Page 15 of 17
15ins•09/08
I
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form t
Subsurface Sewage Disposal System Form Not for Voluntary Assessmen s
0S�-
Property Address /e' ,1
Owner Owner's Name ///l,� Dab Olt—
information
is �— Date of nspection
required for State�/�� Zip Code
every page. City/Town
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells /�S
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health - explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe ho ou establi hed the high ground water elevation:
f--dICJ/
0 �iP C hPJ / rr
,- )-e- . bv" s
Azo��I& —
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 officiai Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
(Sins•09/08
f
Commonwealth of Massachusetts Form
Title 5 official Inspection of for Voluntary Assessments
Subsurface Sewage Disposal System
ST To Nor/ S
r Property Address
Owner Owner shame - �� Oa16 ?� n 0
information is Gtvll'1/1 Zip Code Date of I spec
'on
required for State
every page. 'ILY wn
E. Report Completeness Checklist
Inspection Summary: A, B, C, D, or E checked
Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
Er—system Information — Estimated depth to high groundwater
ZSketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Title 5 ofridal Inspection Form:Subsurface sewage Disposal system•Page 17 of 17
t5ins•09108
1 __ _
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
Z
DEPARTMENT OF ENVIRONMENTAL PROT N
' d S
5�a .
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 72 ST.JOHN STREET HYANNIS,MA 02601 r)n
Owner's Name: SANDY D'ESOPO
PI
Owner's Address: 72 ST.JOHN STREET HYANNIS,MA 02601 MAP 791
Date of Inspection: 4/20/04 PARCEL, ' <Z� U -`,rj 1
Name of Inspector: (please print) JOHN GRACI,INC. �.OT L -
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally P se
_ Needs Further a ation by the Local Approving Authority
_ Fails
' 66
Inspector's Signature: l'L Date: 4/20/04
The system inspector shall submit a co of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspection. I 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.
Notes and Comments
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****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 S TncnPntinn Fnrm 6/1 S/,)nn l 1
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Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 72 ST.JOHN STREET HYANNIS,MA 02601
Owner: SANDY D'ESOPO
Date of Inspection: 4/20/04
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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 PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
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.
n/a 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: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a 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: n/a
IPage3 of 1 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 ST.JOHN STREET HYANNIS,MA 02601
Owner: SANDY D'ESOPO
Date of Inspection: 4/20/04
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.
I. 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 I 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 n/a
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy
of the analysis must be attached to this form.
3. Other:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 ST.JOHN STREET HYANNIS,MA 02601
Owner: SANDY D'ESOPO
Date of Inspection: 4/20/04
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/z day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. (This system passes if the well water analysis, performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be
attached to this form.]
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in
310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large 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.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 1I 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.
a
Page 5 of 1 i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 72 ST.JOHN STREET HYANNIS,MA 02601
Owner: SANDY WESOPO
Date of Inspection: 4/20/04
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period `?
X Have large volumes of water been introduced to the system recently or as part of this inspection'?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up`?
X _ Was the site inspected for signs of break out'?
X _ Were all system components,excluding the SAS, located on site'?
X _ 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
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)]
S
Page 6 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 72 ST.JOHN STREET HYANNIS,MA 02601
Owner: SANDY D'ESOPO
Date of Inspection: 4/20/04
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 0
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): YES
Water meter readings, if available(last 2 years usage(gpd)): nee. (�,2 pro CM/iV►C
Sump pump V
(yes or no): NO v J
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons-- How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X 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): n/a
Approximate age of all components,date installed(if known)and source of information:
1995 PER ASBUILT
Were sewage odors detected when arriving at the site(yes or no): NO
ti
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Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 ST.JOHN STREET HYANNIS,MA 02601
Owner: SANDY D'ESOPO
Date of Inspection: 4/20/04
BUILDING SEWER(locate on site plan)
Depth below grade: 18"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints, venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 12"
Material of construction:Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: L 8' 6" H 5' 7" W 4' 10""
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 0"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related
to outlet invert,evidence of leakage, etc.):
n/a
7
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Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 ST.JOHN STREET HYANNIS,MA 02601
Owner: SANDY D'ESOPO
Date of Inspection: 4/20/04
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into
or out of box,etc.):
D-BOX IS STRUCTURALLY SOUND.
PUMP CHAMBER:_(locate on site plan)
Pumps in working order(yes or no): NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
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Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 ST.JOHN STREET HYANNIS,MA 02601
Owner: SANDY D'ESOPO
Date of Inspection: 4/20/04
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: 0
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
2 leaching trenches, number, length: 30
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,etc.):
THE LEACH FIELD APPEARS TO BE FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF FAILURE.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
n/a
9
Page 10 of 1 I
F
i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 ST.JOHN STREET HYANNIS,MA 02601
Owner: SANDY D'ESOPO
Date of Inspection: 4/20/04
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.
IPage,I 1 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 ST.JOHN STREET HYANNIS,MA 02601
Owner: SANDY D'ESOPO
Date of Inspection: 4/20/04
SITE EXAM
_Slope
_Surface water
_Check cellar
_Shallow wells
Estimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record-If checked,date of design plan reviewed:.n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators,installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 10+FT.
11
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