HomeMy WebLinkAbout0005 SEAGATE LANE - Health 5 Seagate Lane
Hyannis
A = 248 — 026
Commonwealth of.Massachusetts
Title 5 Official Inspection. Form
Subsurface SewageDisnosal System Form -Not for Voluntary Assessments
5 Seagate Ln. Hyannis, MA 02601 �
Property Address ,
Arvydas Klimas PO Box 232
Owner Owner's Name
information is
required for every Fiskdale MA 01518 2/7/2020
page. City/town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness.checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer,
use only the tab Christopher Maki
key to move your Name of Inspector
cursor-do not Cape Cod Septic Services
use the return Company Name
key.
350 Main St.
Company Address
West Yarmouth MA 02673 _
City/Town State Zip Code
508-775-2825 SI-14423
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the.sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
.3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
� II
2/10/2020
Inspector's ignafure Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30-days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time.This inspection does not address how the system will perform
in the future under the same or different conditions of use.
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Commonwealth of Massachusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
5 Seagate Ln. Hyannis, MA 02601
Property Address
Arvydas Klimas PO Box 232
Owner Owner's Name
information is
required for every Fiskdale MA 01518 2/7/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have.not found any information which indicates that any of the failure-criteria described
in 31.0 CMR 15.303 or in 31.0 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System in working condition.
2) System Conditionally Passes:
❑ one or more system,components as described in the"Conditional Pass" section need to be'
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for,°yes", "no"or"not determined" (Y, N, ND)for the following statements.if"not
determined,' please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration.or tank failure is:imminent. System will pass
inspection if the existing tank is replaced-with a complying septic tank as approved by the Board of
Health. /
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if.a Certificate of
Compliance indicating that-the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
5 Seagate Ln. Hyannis, MA 02601
Property Address
Arvydas Klimas PO Box 232
Owner Owners Name
information is Fiskdale
required for every MA 01518 2/7/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution.box due
to broken or.obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
distribution box is leveled or replaced. ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form -Not for Voluntary As
5 Seagate Ln. Hyannis, MA 02601
Property Address
Arvydas Klimas PO Box 232
Owner Owner's Name
information is Fiskdale
required for every MA 01518 2/7/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary(cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the ssystem 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.
El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water.supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form:
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or.system component due to overloaded or
clogged SAS or cesspool.
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
FY Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Seagate Ln. Hyannis;MA 02601
Property Address ,
Arvydas Klimas PO Box 232
Owner Owner's Name
information is
required for every Fiskdale MA 01518 2/7/2020
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool.is less than 6" below invert or available volume is less
than '/ day flow
® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s), Number of times pumped:
❑ N Any portion of the SAS, cesspool or privy is below high ground water elevation.
E ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or,privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
piovided that no.other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead.Protection
Area :IWPA)or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official- Inspection Form
X Subsurface Sewage Disposal System Form Not for Voluntary Assessments
5 Seagate Ln. Hyannis, MA 02601
Property Address
Arvydas Klimas PO Box 232
Owner Owners Name
information is required for every Fiskdale. MA 01518 2/7/2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes" to any question in Section C.5 the system is considered a significant
threat, or answered"yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304, The system owner
should contact the-appropriate regional.office of the Department.
6. You must indicate"yes"or"no"for each of the,following for a//inspections:
Yes No
® ❑ -Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® Were as built plans of the system obtained and examined? (If they were not
available note asMA)
® ❑ 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)]
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Commonwealth of Massachusetts
Title 5 Official. Inspection -Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Seagate Ln. Hyannis, MA 02601
Property Address
Arvydas Klimas PO Box 232
Owner Owner's Name
information is
required for every FlSkdale MA 01518 2/7/2020
page. Cityrrown State Zip Code Date of Inspection
.D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): NSA Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 110x2=
220gpd
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available(last 2.years usage(gpd)): 2018=8gpd
Detail: 2019=12gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
Date
l5insp.doc•rev.7/26/2018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�o Subsurface Sewage Disposal.System Form-Not'for Voluntary Assessments
5 Seagate Ln. Hyannis, MA 02601
Property Address
Arvydas Klimas PO Box 232
Owner Owner's Name
information is required for every Fiskdale MA 01518 2/7/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial,Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap,.present? '❑ Yes ❑ No
Water treatment unit-present? ❑ Yes ❑ . No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: No Records
Was system pumped..as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
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Commonwealth of Massachusetts
Title 5 Official Inspection Form '
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Seagate Ln. Hyannis, MA 02601
Property Address
Arvydas Klimas PO Box 232
Owner Owner's Name
information is
required for every Fiskdale MA 01518 2/7/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
❑ Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes,attach previous inspection records, if any)
❑ Innovative/Alternative.technology.Attach a copy of the current operation and
maintenance contract.(to be obtained from system owner) and a copy of latest
inspection of the'l/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
® Other(describe):
2-Cesspools and 1- 1000Gal leach pit with stone.
Approximate age of all components, date installed (if known) and source of information:
Varies. 60's and added on pit in 1984
Were,sewage odors detected when arriving at the site? ❑ Yes ® No.
5. Building Sewer(locate on site plan): F
Depth below grade: 3'feet
Material of construction: J
❑cast iron ❑ 40 PVC ®other(explain): Sch 20 pvc
Distance`from private water supply well or suction line: +10'
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Line checked with camera and was found to be clean, properly pitched with no sign of root intrusion.
t5insp.doc-rev.7/2 612 01 8 Title.5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 1 a
Commonwealth of Massachusetts
: Title 5 Official'Inspection Form
4 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�V 5 Seagate Ln. Hyannis,.MA 02601
Property Address
Arvydas Klimas PO Box 232
Owner Owner's Name
information is
required for every Fiskdale . MA 01518 2/7/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: teat
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:
Sludge depth:
Distance from top of sludge to bottom of±outlet tee or baffle
Scum thickness
Distance from top of scum'to top of outlet tee or baffle
Distance from bottom of scum,to bottom of outlet tee or baffle
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
- R Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
5 Seagate Ln. Hyannis, MA 02601
Property Address
Arvydas Klimas . PO Box 232
Owner Owner's Name
information is
required for every FlSkdale MA 01518 2/7/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet.tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene
y El other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-page 11 of 18
Commonwealth of Massachusetts
Title 5 Official In-spection Form
Subsurface Sewage:Disposal System Form Not for Voluntary Assessments
5-Seagate Ln. Hyannis, MA 02601
Property Address
Ary das Klimas PO Box 232
Owner Owner's Name
information Is required for every Fiskdale MA 01518 .2/7/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (co'nt.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
`Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert N/A
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box,etc.):
No Box J
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Commonwealth of Massachusetts
153.
lip Title 5 Official Inspection Form
�a Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments
5 Seagate Ln. Hyannis, MA 026.01
Property Address
Arvydas Klimas PO Box 232
Owner Owners Name
information is FiSkdale
required for every MA 01518 2/7/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
t
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
r
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located,explain why:
Type:
® leaching pits number:
1-6x6
❑ leaching chambers number:
El leaching galleries number:,
❑ ' leaching trenches number, length:
El leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Irnspection Form
� a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
;V 5 Seagate Ln. Hyannis,.MA 02601
Property Address
Arvydas Klimas PO Box 232
Owner Owner's Name
information is required for every Fiskdale MA.- 01518 2/7/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System,(SAS) (cont.)
Comments.(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
1-64 Leach pit with.stone. Pit found dry during inspection with no evident stain. No sign of
overloading or hydraulic failure.
12. Cesspools (cesspool must be pumped as part of inspection) (locate.on site plan):
Number and configuration 2-1 Main, 1 Overflow
Depth.—top of liquid to inlet invert
Dry
Depth of solids layer, N/A
Depth of scum layer N/A
Dimensions of cesspool 6x8'
Materials of construction Concrete Block
Indication of groundwater inflow - ❑ Yes ® No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
1 Main cesspool and 1 overflow cesspool in good condition. Both pools found dry. Main acting as
septic tank from house. Overflow tied in between main and leach pit. No signs of hydraulic failure.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form'
JSubsurface Sewage,Disposal..-System Form-Not for Voluntary Assessments
5 Seagate Ln. Hyannis, MA 02601
Property Address
Arvydas Klimas PO Box 232
Owner Owner's Name
information is
required for every Fiskdale MA 01518 2/7/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,'signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
5
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
,T Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5 Seagate Ln. Hyannis, MA 02601
Property Address
Arvydas Klimas PO Box 232
Owner Owners Name
information is required for every FlSkdale MA 01518 2/7/2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
❑ hand-sketch in the area below
®drawing attached separately
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
°y Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�u•' 5 Seagate Ln. Hyannis; MA 02601
Property Address
Arvydas Klimas PO Box 232
Owner Owner's Name
information is
required for every Fiskdale MA 01518 2/7/2020
page. Cityrrown State Zip Code Date of Inspection
D. System Information (coat.)
15. 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:
Hand auger through bottom of dry pit did not encounter water at 121.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Fla Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
5-Seagate Ln. Hyannis, MA 02601
Property Address
Arvydas Klimas PO Box 232
Owner Owner's Name
information is FiSkdale
required for every MA 01518 .2/7/2020
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3; or checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6~(Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping.contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation'of estimated depth to high groundwater included
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
LOCATION SEWAGE PERMIT N0.
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BUILDER OR OWNER
DATE PERMIT IS5,1110 1O• Iv.
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LOCATION tq SEWAGE PERMIT NO.
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Q U I L D E R OR OWNER
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DATE PERMIT ISSUED to. IF. FsL
DATE COMPLIANCE ISSUED
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O a-ko THE COIVMONWEALTH F ry s BOARD OF HEALTH
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AppfirFatiun for Mivasal Works Tunuarurtiun Frrutit
Application is hereby made for a Permit to �-,opstruct or Repair ( ) an Individual Sewage Disposal
System at: �.4a
...../..�......IS-1 ... •- ................•-----•-------.....•................................--
Loc n-Address or Lot No.
..... ._........ ............ .. ........................... ...............
— •-------•---------- --------------------
Address
Installer Addres
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms._._.______________________________Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type T e of Building No. of persons............................ Showers — Cafeteria
a yP g P ( ) ( )
a Other fixtures --------------- -----------------
W Design Flow........... ..................gallons per person per day. Total daily flow........ _1.4_........................gallons.
WSeptic Tank—Liquid capacity............gallons Length---------------- Width---------------- Diameter---------------- Depth................
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) I Dosing tank ( )
PercolationTest Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water..........._............
0-4
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------••••--------••--------------••-•------------------.._.............................-•---•••--.........................................................
ODescription of Soil...........................................................................................=............................................................................
x
W -----------------------------------•---------------------------------------..._...--------------------------------------------...--------------------------- ••----
UNature of Repairs or Alterations—Answer when applicable.. _..__a ------l Q 4 O-_-_ ......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of L I'i U 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance d b the bo lth.
Signed------= --•----•--.---.._ ...
Date
Application Approved By..................................
.l d..-...-...-- ...e ------
Date
Application Disapproved for the following reasons:................................................................................................................
....................•--•-•---------.........------------------------------•-------------------------•------•--------------------••----••---------------•---------------------•-----------•---........._
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
It
BOAR® OF HEALTH
..........................................O F.......................................
ApplirFation for Disposal Works Tonitrnrtion amit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
. ........................................................................
Location-Address or Lot No.
�.:.ty:{l?�-.-' .......................... ............. •r .:!:: �s1:�::x-7n,.........................................................-....__ ...
owner �w 1 J� Address
................?. .. .._...-•�.........is' -�` cn ............. •...._�'�•-�r„-•_!_- 3!�..f'�!L!ie6:@.---��':2'n.:?..:E�.............--•---.
Installer Addres`
Type of Building Size Lot___________________________Sq. feet
U DwellingNo. of Bedrooms-_-._. Ex Expansion Attic
a — .............................. p ( ) Garbage Grinder ( )
al Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ............... ••---•-•------•-••......---------•--.••-•-•--••-- • .
W
Design Flow.......... _____________________gallons per person per day. Total daily flow....... -?-........................__gallons.
Septic Tank—Liquid capacity............gallons Length---------------- Width................ Diameter................ Depth____-____._.....
x Disposal Trench—No_____________________ Width.................... Total Length.................-__ Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by....................................
-•-•---------•--•-•------------------ Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit_.----.-_.._________ Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ........................................
...................
-------------------•---------------------------------------------------------------------------••-
0 Description of Soil...........------------------------------------------------------•--------•--------------------------•---------------•---------------------------------.............---
W
w
U Nature of Repairs or Alterations Answer when applicable ,0- .0 .....1_C-a_c'-?..__� � `�_____-_.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITL1 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance beenissu,ed by the board of ealth.
Signed-.....N7 . .. z.-4................... ....I...........................
-
Date
Application Approved By................................. ....................................... Z4�-_A*-------------/......_
Date
Application Disapproved for the following reasons-------------------------------------------------------------------------------------------------•------•---•-•--
----------------------------------------------------------------•---------------------------------••----...
---------------------------•------------------------------------------------
�I
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........OF........ Icr-' :.h................................
Tntifiratr of TompliFanrr
TAIS IS.TO C RTIFY ThaX the irxctidu Se age Disposal System constructed ( ) or Repaired ( )
BY �-s t'' r'
�r
j Installer
at.............. . ......ba
has been installed in accordance with the provisions of TITLE 5 of Thee State Sanitary Code as described in the
application for Disposal Works Construction Permit No-----��?�------ ......... dated------------------------------------------------
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. -;
DATE................................................ ........ Inspector---
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
c-
No FEE../.�L..............
;Dhglpsa-l- o ko To lerutt�
Permission is hereby granted' ��'``...._....._.. := .
to Construct ( ) or Repair ( ) an Individual Sewage Disposal System
atNo........................... AA-g-e�.� - ` 'b `= --------------------------------------------------------------
Street
as shown on the application for Disposal Works Construction Permit
tNNo..................... Dated_.- _.. 4 .........
Board of Health
DATE-----------------------•----------•----....._..._._..._._.....-•---•-••--......
FORM 1255 A. M. SULKIN, INC., BOSTON
1/31/2020 ShowAsbuilt(1700x2800)
d� LOCATION SEWAGE PERMIT NO.
lJ Sewa�ie Lrwe bg.9+L
VILLAGE
1-AYANNIS Ms:
INSTAtLER'S NA-ME 18 ADORESS
23 SE_NN�ES �-AT41 �.nri
BUILDER OR OWNERR
OATS PERMIT ISSUED Ip.IF $y
DATE COMPLIANCE ISSUED
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