HomeMy WebLinkAbout0119 SEAGATE LANE - Health kl l9 Seagate Lane.
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TOWN OF BARNST"LE
LOCATION i \ �( 5 ��t ti� SEWAGE# \57- 1
VILLAGE ASSESSOR'S MAP.&PARCEL
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INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(typetJS Sdo G A4' 'zo,,E(size) -S—s it _'3'4
NO.OF BEDROOMS
OWNER
PERMIT DATE: COMPLIANCE DATE: 4 r' /
Separation Distance Between the:
v
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility .Z> Feet
Private Water Supply Well and Leaching Facility(If any wells exist on`
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
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No. l ,3 Fee ��
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: /
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2ppYiration for Misposal 6pstetn Construction 3permit
Application for a Permit to Construct( ) Repair( ) Upgrade(I�bandon( , omplete System ❑Individual Components
Location Address Loft jNo. 9 SECT�',4�9A1 E Owner's Name,dress,and el.No.
h, 1"� S��iAg-J,,, &¢v A-IP�'
Assessor's ap arse 'Vd �l V
I ller's Nanle,Address,and Tel.No. 5 o9 9/o77,2-6-0 Designer's Name,Address,and Te.No.,SG%�1 3( 7>6/7
rd�/7
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.$. Garbage Grinder
Other Type of Building 52 cFJr);2 No.of Persons Showers(_) Cafeterias—}
Other Fixtures
Design Flow(min.required) L,ln gpd Design flow provided gpd
�T
Plan Date $ / Number of she is Revision Date ----
Title
Size of Septic Tank Type of S.A.S. — 5-M&A 144,U
Description of Soil S e�
Nature of Repairs or Alterations(Answer when applicable) L
/ e
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 Certificate of
Compliance has been issued by this Board of ealt .
I
Sign d Date S7
Application Approved by. t6fDate �
Application Disapproved by Date
for the following reasons
Permit No. (. 3 1:7 Date Issued
i
No. ( ) 3� {. s _.. Fee / (/
THE COMMONWEALTH OF MASSACHUSETTS Entered in compute
- PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
21ppliratlon for Mid al 6pBtem Construrtion permit
Application for a Permit to Construct( ) Repair( ) Upgrade(!,)'Abandon( ) Complete System ❑Individual Components
Location Address or Lot No.//9 S �I"69 �g,!'JQIIE Owner's Name,Address,and Tel.No.
A/ess�'s-Ivlap/�'are'ef' * - !d C7
Alle Is Narrle,Address,and Tel.No. S09 9,?7,VSa,Z Designer's Name,Address,and Te.No.j d�5 3 Fj 7/6/T-
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder
Other Type of Buildings/0 r,,Jc, No.of Persons l Showers Cafeteria()
Other Fixtures
Design Flow(min.required) �� gpd Design flow provided gpd
Plan Date /5 /,ST Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. -,5-�`"A[
Description of Soil $c A
`- Nature of Repairs or Alterations(Answer when applicable) ow L
[�� S o
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 Certificate of
Compliance has been issued by this Board of Healt .
Signtd Date -
Application Approved by vu Date `s "
Application Disapproved by Date
for the following reasons
Permit No. :�j( Date Issued G/�/ ;71/ j'
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
(Certificate of Compliante
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ) Upgraded(�
Abandoned( )by y%ki G\5 ) A,r
at i / '�E.4 LU1 T %%Ak dJl S has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. d 1 ?dated i
Installer (A) SE1L ri�00 6Z l Z IF Designer d
#bedrooms Approved designrlgw A AA gpd
The issuance o this permit shall not be construed as a guarantee that the system will nctio a design°.
Date 9 �J-! Inspector ,1n �5
l C7
----- ---- -- --- ------------_----------------------------------------- --------------------------------- -------------------
No. - -
/ Fee /dv
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal *pstem ConstrUrtion 3permit
Permission is hereby granted to Construct( ) Repair( ) Upgrade(V/) Abandon( )
System located at
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions. r
Provided:Cons ction must be completed within three years of the date of this permit.
Date � r l ! Approved by
Town of Barnstable
lime
r o Regulatory Services
r s
Richard V. Scali,Interim Director
* BARNSTABLE, '
MASS. ��� Public Health Division
c3+° Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: q Z�J Sewage Permit# Sul r S� Assessor's Map�Parcel 2_411
Designer: 1 1 Installer: Wftl�Y z
Address: �"'li/✓ `�`1`^► Address: �L
On was issued a permit to install a
(date) (installer)
septic system at LA4(& based on a design drawn by
( ddress)
• dated -
designer
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Strip out (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow. Strip out(if required) was inspected and the soils
were found satisfactory.
I certify that the system referenced above was construct_ '' ce with the terms
of the IAA approval letters ' plicable) qss
DAVID s4\t
B.
MASON ` `1.
(Inst er's ign tur v No.1 066 j
SgAlITAR\N
( esi s Signature (Affix Designer s Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Septic\Designer Certification Form Rev 8-14-13.doc
Bedroom Count Affidavit for 119 Seagate Lane, Hyannis, Massachusetts
This shall act as an affidavit that the property at 119 Seagate Lane, Hyannis,
Massachusetts has been a four (4) bedroom dwelling since the dwelling was built
in 1965 as shown on the floor plan prepared by David B. Mason, RS, dated
September 15, 2015.
Randy Wickersham, Trustee for Shirley Anderson Revocable Trust
I'
AsBuilt Page l of 1
LOCATION SEWAGE PERMIT MO•
VILLAGE —"
Ir - �%� lyt �
INSTA LL R'S NAM R ADDRESS �"
I
R U I L 0 E R OR OWNER (2mn.
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED4
a� S 34
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=249040&seq=2 8/17/2015
Town of Barnstable P# '�$07 �yw
oFTME `
yvQ Department of Regulatory Services
+ BABN31'ABLF
Public Health Division Date 8 �b
MA99.
200 Main Street,Hyannis MA 02601 cc I
s
Date Scheduled t Time Fee Pd. / J1Y)-"CW
^y
Soil Suitability Assessment for Sewage Dis osal
.� .S
Performed By: ' �, c_i/�l..V�•l Witnessed By:
2
i^
LOCAT�I�OjNN&GENERAL INFORMATI)O1N��
Location Address �11-1 � Owner's Name��ll�j�'t/�.,t9(�Wl
Ali
` 'I(uP4I M�r[]1�' Address �r
t _ Assessor's Map/Parcek '�L.�QW, 'Y.� // _ Engineer's Name /✓fit,"AW,--0"v
NEW CONSTRUCTION REPAIR ✓ Telephone# �vv -3(o-7461-1
Land Use Slopes(%) + Surface Stones
Distances from: Open Water Body ft Possible Wet Area ft Drinking Water Well ft -
Drainage Way ft. PropertyLine ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test h s&perc tests,locate wetlands in proximity to holes)
Parent material(geologic) - Depth to Bedrock
Depth to Groundwater:Standing Water in Hole: Weeping from Pit face
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used:
• Depth Observed standing in obs.hole:, in. Depth to soil mottles: in.
Depth to weeping from side of obs.hole: - in. Groundwater Adjustment ft. .
Index Well# Reading Date: Index Well level _ Adj.factor Adj.Groundwater Level
PERCOLATION TEST Date Time
Observation
Hole# 4—M-4
Time at 9"Depth of Perc Time at6"Start Pre-soak Time @ � Time(9"-6")
End Pre-soakRate Min./inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(YIN)
Original: Public Health Division Observation Hole Data To Be Completed on Back-----------
k .
***If percolation test is to be conducted within 100'of wetland,you must first notify the
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTIC\PERCFORM.DOC.
4 /,Ow Vvs
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
.. Surface(in.) (USDA)• (Munsell) Mottling (Structure,Stones,Boulders.
/�y Consistenc %Gravel
PYU
0�
1 , I
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Graven
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture• Soil Color 'Soil Other
Surface(in.) _ (USDA) (Munsell) y Mottling (Structure,Stones,Boulders.
Consistency,%Graven
DEEP OBSERVATION HOLE LOG Hole,#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consistency.%Graven
Flood Insurance Rate May: y/
Above 500 year flood boundary No ,,/es V
Within 500 year boundary No
Within 100 year flood boundary No
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pery o t * l exist in all eas observed throughout the
area proposed for the soil absorption system? ,� yy
If not,what is the depth na Ily occurring pe r ious material? �'�I
Certification �{
I certify that on L (date)I have passed the soil evaluator examinatio approved by the
Department of Enviro a Protecti and at a above analysis was pe orm by me consistent with
the ren
g,exp rtis and e e enc des bed in 310 CMR 15.017 J
Signature Date I ��
t ,
Q:\SEPTIC\PERCFORM.DOC
LOCATION SEWAGE PERMIT NO.
VILLAGE
ks
INSTA LL R'S AM ADDRESS
DUILDEIt OR OtMER (e-yln,
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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...... FRA... ............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
......................T.own....OF.......Barnstable.....
Appliration for Bi-gVogal Works Tontrnrtinn rrmft
Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal
System at:
119 Seagate Ln., _ ]Cl;� Hyanffiis, -MA 02601
.------• •-------------••-•-•----....---...---.............--------..._............--.......•••---
Location-Address or Lot No.
61enn. Anderson 11 Sea ate Ln. H annis MA 0�601
. __
....-- �.. Y.. ... :.................... . .......
ar Address& B Cesspool Service 128 Bishops Terrace........................: aH
is M 02601
Installer Address
Q Type of Building Size Lot--.- -----_ _------Sq. feet
aDwelling—No. of Bedrooms....... Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons_..k...................... Showers ( ) — Cafeteria ( )
Otherfixtures --------------------------------------------------------------------------------------- -------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic 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 ( )
aPercolation Test Results Performed by.......................................................................... Date------------..--------------------------
a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.--------..-_.._._---.-_
fT Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Ix -•----------------------•---•----•-------••--•---•--------•-•--•-------------------------.......--•........................................................
0 Description of Soil..............Sand----------------=-----------------•----.....----•-------------....---------------------------------------------------------------•----------....
x
W
UNature of Repairs or Alterations—Answer when applicable._-_.-..- Ills.ta. J.a.ti.on---of...a_-l+D_00._.gallosl,_pre-cast
stone packed leach_pit___(oyerfl_ow,_...............................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TIT .
p 5 of the State Sanitary Code— The undersigned further agrees not to e the system in
operation until a Certificate of Compliance has been issued by the boar of h
Signed...... .l�......... .... ....... ----------------------- ------ ---------7.0/2Q4$0......
Date /
Application Approved BY - �l' -f� . -----•--------------------•-•-- --•---••-----•-1Q/2q<-80------
Date
Application Disapproved for the following reasons:---•---------------------•------•--------•------------....----••---------•-----------------------•-•----------•-
..........................................................................................._...................................................................................................
Date
10 20 80
Permit No..80- -•------------------•--•------------=-------- Issued_.........----�----�---------......-•-•---•--------
Date
NoB.O=...a�'.76..... FE4...5. 00............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................j.own....OF.........�xnstabl$....--------
Appliration for Uigpoiial Worse Tomitrortion ramit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
llg lK13 � Z9 H,yanis,,_NA 02601
.--•------•----•--...---•------•-.........-•-•----•--------------••-•------••-•-•....--
Location-Address or Lot No.
.�1enn Anderson 110_SeagateLn.=_Hyannis, lA,_ Ot601..............
Qwner Address
a A&.B Cessrool Service 128 Bishops Terrace, Hyannisa MIA 02601_____
Installer Address
� Type of Building Size Lot............................S q. feet
�-, Dwelling—No. of Bedrooms........... ..............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons___y:...................... Showers ( ) — Cafeteria ( )
Otherfixtures "---------------------------------------------------------------------------------------....-----------------------------------------•--•••---•------..
WDesign Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length................ Width................ Diameter................ Depth..........:....
xDisposal 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 ( )
aPercolation.Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1..:............minutes per inch Depth of Test Pit.................... Depth to ground water.....................
rZq Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
� ------..............................................-••-----------•--•-------------••-•-•----------........................................................
0 Description of Soil..............Sand
x ............---..................................................................................................................................
U --------------------•- :.....................................-.....................................................................................................................................
W ------•-------------------- ---------------------------------
� ---- -- ---
U stone acked leach it over /, --------- InstA11_4 on---Of__4.1-,00..allm..._pxe.-cast
Nature oPRe airs o: Alterationsp ---( --Answer w/hen applicable^ --•--
Agreement:
The undersigned agrees to install the aforedescribed Individual.-Sewage Disposal System in accordance with
the provisions of-TT
LE 5 of the State Sanitary Code— The undersigned further agrees not to lase the system in
operation until a Certificate of Compliance tias/;been issued by the board
he"-the
•
Sign ._. t ��a: �. _ .._ c 10�Z0,i�0.....
D to
Application Approved BY --t ac.. •---------•----•-•. ........ 10�20A0.....
Date
Application Disapproved for the following reasons----------------•--------------------------------------------...................................................
......................................----------------- ---•-------------•------------............------
Date
Permit No... ... 0
......... 1.. 2 iI0
...................................... Issued....------------------------------•-----------•------- '
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town O F.........Barnst. . able.......................... ....... .. .....
C�rdifiratr of Tootpliattrr
I �
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( X) 1
bY......... . -- eS �9Q�._Se7 'i re...1ZS.. isho�s__ ax:ra��...�Iyann�. Q2 o1.- 7 5-b254.....-----
Installer q
at........119... ----------...................................................
has been installed in accordance with the provisions of TITLE j of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No----- ................ dated_---------10/29/80.................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS tGUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. �
DATE.....--- .................................................... Inspector �4_ z, -• ---------.....---•--------.......--..--••-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T own..........®p............BarnstalAe 5 00
No.8Ll-..... .
�.... FEE.................. .
�i��oo�l or�o �oatotrion proti�
Permission is hereby granted A &--------F ice
-- -•---Cessool Sery---------------------------------------------------------------••-•---•........
to Construct j �) or Repair ( X)an Individual Sew e Disposal System
at No........11 Seagate Ian., yannis, ILA ON& - Glenn Anderson
•. .. ---- ---- ----------------- ---
Street
as shown on the application for Disposal Works Construction Permit No._8Q_'.........._ Da�ted_.....W2.0180
10/20/80
Boa o Health
DATE................................................................................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
Commonwealth of Massachusetts
5= (./ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/ 119 Seagate Ln
/ Property Address
Renata Viera M_orais
Owner Owner's Name 71
in6rmation is 11 anniS ma 02601 8/6/15
required for every _Y
page. Citv/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. General Information
on the computer,
use only the tab 1. Inspector: ! v
key to move your
cursor-do not Michael DiBuono
use the return Name of Inspector
key.
DiBuono Sewer and Drain _
rsa Company Name
8 Johns path — -— --- —-- —-----
Company Address
ew, S Yarmouth _ MA 026_64 _
City/Town State Zip Code
508-364-9587 S113522
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was,performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
�D�_ctcis
8/7/15nture Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
or 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.
't wr i (51ns•N13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
,ek
! 3 w
` 4
Commonwealth of Massachusetts
W Title 5 Official Inspection-' Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Seagate Ln
Property Address �—
Renata Viera Morais
Owner Owner's Name
information is annls ma 02601 8/6/15 required for every H—Y _
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:
The system fails in accordance with Barnstables ruling of a single Cesspool is an automatic failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" secticn need to be
replaced or repaired. The system, upon completion of the replacement or repa r, 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System.Form - Not for Voluntary Assessments
119 Seagate Ln
Prcperty Address
Renata Viera Morais
Owner Owner's Name
information is required for every �H annis ma 02601 8/6/15
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 ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ ,Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
F
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113: Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
4i,M A
119 Seagate Ln
Property Address —
Renata Viera Morais
Owner Owner's Name
information is
required for every Hyannis ma 02601 8/6/15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a seotic 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 ajsent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, proviced 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
gg 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 f/2 day flow
15ins-3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Seagate Ln
Property Address
Renata Viera Morais
Owner Owner's Name
information is
required for every Hyannis ma 02601 8/6/15
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.
I .
❑ E Any portion of a cesspool or.privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 119 Seagate Ln
Property Address
Renata Viera Morais
Owner Owner's Name
information is required for every Hyannis ma 02601 8/6/15
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:
9
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?
Y P
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as ouilt 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:
® ❑ Existina information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3113 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Seagate Ln
Property Address
Renata Viera Morais
Owner Owner's Name
information is required for every Hyannis ma 02601 8/6/15
_
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system fails in accordance with Barnstables ruling of a single Cesspool is an automatic failure.
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ❑ N.o
Water meter read in s, if available last 2 ears usage d Na
9 ( Y 9 (9P ))�
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:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface S _ewage Disposal System Form Not for Voluntary Y to Assessments
Y
�M 119 Seagate Ln
Property Address
Renata Viera Morais
Owner Owner's Name
information is
required for every Hyannis ma 02601 8/6/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Na
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
❑ Septic tank, distribution box, soil absorption system
® Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight g t tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts d
Title 5 Official Inspection Form
I. Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Sea ate Ln
9
Property Address
Renata Viera Morais
Owner Owner's Name
information is required for every �H annis ma 02601 8/6/15
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:
50 + years
Were sewage odors detected when arriving at the site? ❑ Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 18"feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
System is vented throught the roof.
Septic Tank (locate on site plan):
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:
Sludge depth:
t5ins•3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
H,�•'I, .•tea-,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Seagate Ln
Property Address
Renata Viera Morais _
Owner Owner's Name
information is required for every Hyannis ma 02601 8/6/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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 reccmmendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
ILE
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
119 Seagate Ln
Property Address
Renata Viera Morais
Owner Owner's Name
information is required for every Hyannis ma 02601 8/6/15
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.-
El concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract (required). Is copy attached?,,. ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page.11 of 17
Commonwealth of Massachusetts
r
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 119 Seagate Ln
Property Address
Renata Viera Morais
Owner Owner's Name
information is Y required for every —H Ennis ma 02601 8/6/15
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 Na
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Seagate Ln
Property Address
Renata Viera Morais
Owner Owner's Name
information is
required for every Hyannis ma 02601 8/6/15
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:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: Single Cesspool
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
t51ns•3/13 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17
Y
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Seagate Ln
Property Address
Renata Viera Morais
Owner Owner's Name
information is
required for every Hyannis ma 02601 8/6/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.)-.
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 14 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
. 119 Seagate Ln
Prcperty Address
Renata Viera Morals
Owner Owner's Name
information is required for every Hyannis ma 02601 8/6/15
-
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
p Y 9 P 9 Y 9
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
i
r
Jf
t5ins•3113 _ - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
.l
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Seagate Ln
Property Address
Renata Viera Morais
Owner Owner's Name
information is required for every Hyannis ma 02601 8/6/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
Check Slope
p
® Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 15 + ft
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
119 Seagate Ln
Property Address
Renata Viera Morals
Owner Owner's Name
information is required for every Hyannis ma 02601 8/6/15
-
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•3113 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 17 of 17
w�O `
i
rOY , IARINSTABLE
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02
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n
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"VASSESSORS MAP : �z�9
� PARCEL �`-�o _ �-- --,� TEST HOLE LOGS
1) The installation shall coaffp j %vitlf Title V and -town of l l jl .Ioard of
FLOOD ZONE: A/p j ,P-��� L SOIL EVALUATOR : � to d5E_ I lealth Itegulalions.
REFERENCE: WITNESS : 2) The installer shall verily the location of utilities, sewer inverts and septic
Z DATE: components prior to installation and setting base elevations.
PERCOLATION RATE: -L z J / 3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8" per loot. The first
q. �.. f two Ieet out of the d-box to the inchingshall be level.
� Y• �� `��}� v' b� 4) This plait is not to be utilized for property line determination nor ally other
f � TH- I TH-2 purpose other than the proposed system installation.
�- J¢ L.v4 � �i ��c`> 5) All septic components must meet Title V specifications.
!/pU 1 6) Parking shall not be constructed over I110 septic components.
J-04 6+,LQ 7) The property is bounded by property corners and property lines.
_._ ti� 8) The property owner slfall review design considerations to approve of total
LOCATION MAP - � -�
design flow and number of bedrooms to be considered for design. Receipt
t�1 10w RL�JC, P 5
j - C C of payment for the plan and installation based on the plan shall be deemed
Zt7 Q,• z Pup,�_7 019WZ 1� 1DI D-7 � �Oy,t-'r � approval of the design flow by the owner.
existing leaching or cesspools shall be pumped and filled with material
A ifcD, --t per Title V abandonment procedures. Those within the proposed SAS shall
?j Iafe.7 z> ID �ll� be removed along with contaminated soil and replaced with clean sand per
'title V specs.
10)System components to be 10 feet from water line. Sewer !ines crossing the
water line shall be sleeved with 4 inch SCt 140 PVC with ends grouted if
1 gp applicable. The proposed SAS is being installed below the water service
Yx 7� line. 'fhe line is to be sleeved as aforementioned and maintained in place.
S
r�7 „_.._,L,�9�1C _ __. SEPT ] C SYSTEM DESIGN t 1) If a garbage grinder exists it is to be removed and is the responsibility of the
owner to ensure such.
--- FLOW EST I MATE 12)"I he installer is to take caution in excavation around the gas line if such
exists.
l3)Tite installer shall verify the location, quantity and elevation of the sewer
- _ iC✓� c3� I S�3 oC� �/ _ _ BEDROOMS AT I�t� GALIUAY/BEDROOM - 7� GAL/DAY � Y_ ^ q Y
` I0 ,[)C>i lines exitinp the dwelling prior to the installation.
t
I
I SEPT C TA14K 14) I his plan is representative only that a system cart fit oil property meeting
> ( Title V requirements.
GAL/DAY x 2 DAYS - GAL
USE , GALLON SEPTIC TANK
0) I {//��,, I O� SOIL AB ORPT I ON-SYSTEM
(V\ r
— 0 Al
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ID217 =
i�I SIDE AREA - �28DAOV
BOTTOM AREA 1� ASON y
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SEPTIC SYSTEM SECTION
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3 5c3 0 0 1 _ ►y.'3aFIF 2,�2 Ur gi,wt
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SEPTIC TANK
. 7
SITE AND SEWAGE PLAN
`� LOCATION : 1 I w0A, A L.
V VI�4I
P
PREPARED FOR : E Y -1
M
ICALE.
DAV I D B . MASON R5 DATE: 11,5120,
g DBC ENVIRONMENTAL DESIGNS
DATE HEALTH AGENT
EAST SANDWICH . MA
( 508 ) 833- 2177