HomeMy WebLinkAbout0006 SECURITY STREET - Health 6 SECURITY STREET, HYANNIS
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TOWN OF BARNSTABLE
LOCATION 41-2 �2 C ca,d 1 � �� SEWAGE
Va:LAG E Q dl j'1 =S ASSESSOR'S MAP&1LOT
INSTXL)LEWS NAME&PHONE NO.
SEPTIC TANK CAPACITY �.�—.
Ce � .�
�LEACHING FACILITY' (type) � (size)
NO.OF'BI GROOMS. ..._
BUILDER OR OWNER,
PERMIT®ATE:,_._,,,,,_._. :COM.I'IaIA► CE DATE:
Separation Distance Between the'.
Maximum AdjustecJ Groundwater Table to the Bottom of Leaching Facility Ecet
PrWke,dater Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetdansd acid Leaching Facility(If any wetku s exist
within 3t0 feet Imbin�.facili ) - T<ee
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Furnished by.. A L
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TOWN OF BARNSTABLE
LOCATION
S,re 6 E' 2rJ L SEWAGE # 13
VILLAGE_/ ld / ASSESSOR'S MAP &LOTS
INSTALLER'S NAME&PHONE NO. 2d
SEPTIC TANK CAPACITY .f i� L/
LEACHING FACILITY: (type) "lf (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMTTDATE: COMPLIANCE DATE: f
Separation Distance Between the: -
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) Feet
Edge of Wetland and Leaching Facility(If-any wetlands exist
within 300 feet of leaching facility.) Feet .
Furnished by
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TOWN OF BARNSTABLE
.00ATION /1 � SEWAGE
IXLLAGE /144 n cs ASSESSOR'S MAP&LOT
NSTALLEIt'S NAME&PHONE NO.
i6PTIC TANK CAPACITY I SDI
.EACHING FACIILITY: (type) l'u� (size)
(O.OF BEDROOM' ._�_._.:
WILDER OR OWNER..
'BRMI<TDATE: _ ,.� COMPLIANCE DATE:
;operation Distance Between(be:
Aaximum Adjusted*Groundwater Table to the Bottom of Leaching Facility ... Oct
'rivate!Water Supply WoU and Leaching Facility (if imy wells exist
on site or within 200 feet of leaching facility)
idge of Wedand and Leaching Facility(If any wetlands exist
within 300 feet of 1 ung facili ty) rect
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i,Vrnishcd by _ abvil
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No. �0 Fee_$SO . 00
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
Application for 3Di!6poga1 *pgtem Construction Vermit
Application for a Permit to Construct( )Repair( x)Upgrade( )Abandon( ) ❑Complete System O Individual Components
Location Address or Lot No. 6 Security Rd S"T Owner's Name,Address and Tel.No. 7 81 —6 4 6—8 0 6 0
Assessor'sMap/Parcel Hyannis, MA Carolyn Harris 11 Brattle Dr A rt 11
Arlington, MA 74-286
Installer's Name,Address,and Tel.No. 7 7 5—8 7 7 6 Designer's Name,Address and Tel.No.
W E Robinson Sr Septic Sry
PO Box 1089, Centerville, MA 0263
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( n6
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer.when applicable) Title 5 Septic consisting of
1500g tank, D—box, and 2 500—gallon precast leach chambers
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 by this o Health.
Signed of Date �5
Application Approved by Date ,-30'
Application Disapproved for the following reasons
Permit No. Z Z 3 Date Issued ""/c
I ..;':5ts -v.i'w`�n.y+r..,..r.;�'s^r .w'">-..,yMv^�1X'�, .J �i ' "., � i - • , .'yr,.. :;ry._. .. ....._� �. .�:.:,. .. .. .. ..rq-.�"' « ri✓A{teY:.
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF.BARNSTABLE., MASSACHUSETTS
01ppgication for Mt�tlO�aY 6pgtP" � Congtructivr� eru�it
Application for a Permit to Construct.( )Repair( g)Upgrade( )Abandon(,_,) ❑Complete System ❑Individual Components
Location Address or Lot No. Owner's Narde,Address and Te '
6 security 8d S-rr -781 -646-8060
Assessor's Map/Parcel Hyannis, MA Carolyn HarC3s 11 Brattle Dr Art 11
Arlington, MA 74-286'
Installer's Name,Address,and Tel.No. ]7 5—8 7 7 6 Designer's Name,Address and i�1.Mo.
W E Robinson Sr Septic Sry ,-
PO Box 1089, Centerville MA' 0263 '
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft.. � Garbage Grinder( n6
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S. "
Description of Soil sand
y
Nature of Repairs or Alterations(Answer when applicable) Title 5 Septic consisting ofi€
1500q tank, D-box, and 2 500-gallon precast-- 1Pat--h chambers ,
17ate last inspected: t
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 by thimspoapro of Health.
1 Signed Date
Application Approved by Date ` -30
Application Disapproved for the following reasons
Permit No. 2 '7 1 Date Issued
- ------ — -- -
/ THE C-OMMON�WEA�1,H OF MASSACHUSETTS r
Harris
`BAR�V$fiABLE, MASSACHUSETTS "3
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaire&(xx)Upgraded( )
Abandoned( )by
at 6 Security Hyannis has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 Z 73 dated 41—.34
Installer W E Robinson Santi C Sry Designer
The issuance of thy' -permitlskll nojbe«yonstrued as a guarantee that the system will ction as designed.
Date ( ® / �" Inspector
No.— Z-7-3----------------------------Fee 50.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Harris Mizpozar *pgtem Cori.5tructiou Permit
Permission is hereby granted to Construct( )Repair(xx)Upgrade( )Abandon( )
System located at 6 Security Rd-5
Hyannis, MA
Installer: W E Robinson Septic Sry
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.
Provided:Construction must be
completed within three years of the date of this permit. (�
Date: ! `V ® "/� Approved by � ` • lJ
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
I, William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at 6 Security St, Hyannis, meets all of the
following.criteria:
* There are no wetlands within 100 feet of the proposed leaching facility.
* There are no private wells within 1.50 feet of the proposed septic system.
* There is no increase in flow and/or change in use proposed.
There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map), L
B)Observed Groundwater Table Evaluation(according to Health Division well map)�3
SIGNED: DATE
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE'NUMBER 20-1998'
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
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Commonwealth of Massachusetts 0*8-80
Title 5 Official Inspection Form
Subsurface Sewage Disposal SyMerr Frsr'm Nci� lbrVol4rntaRr Assesr:rnents
Property Address -. ___�__._S o
4 �/ 1 C.
Owner infoinvftri is Owners Name __-•_•_
required for every / ,cA/
page.
ZiWf own ad�o��
Sate Zip Code hate of I s pect n
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.
Im Ming
When A. General Information
fllfing out forms
on the computer,
use only the tab Inspector.
key to move your
cursor-do not
use the return a Y
key, Name of Inspector
Company Name _
Company Address --
city ow State �Ol
S o i (Jr&— 7 / Q Zip Code
1—phona-mmber 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"10C15.000). The system:
Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Inspect Cs Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of i 0,000 god or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DER 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.
t9ns•3P13
Title50ffiaal Inspection Fars Subsuface sewage Disposal System-Page l of17
�b9q� •S
VJ
Commonwealth of Massachusetts
lug Title 5 Official Inspection Form
Subsurface Sewage. Disp6saI System Form -Not for Voluntary Assessments
6 SCE C rrt s
Property Addren / l
Owner Ovv
information is oar's NaRte
ma
required for every ✓t vi
page. tatylTovvn State Zip Code Date of I spec n
B. Celrtification (cons.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) Syste 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`y+es "no"or"not determined"(Y,N, ND) for the following statements. if"not
determined,"please ex0ain.
I.
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 tJ at the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
i
f5ro•3M 3
Title 50Fficial Inspeetim F ornr Subsurtace Sewage Disposal System•lyage 2 of 17
Commonwealth of Massachusefts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Se Cure
Property Addre ss
Om►ner ;0wner's Name
information is
required for every yi N a 8
page. Rown State Zip Code Date of Ins c0
�o Certificai:iion (corn.)
❑ 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 CHAR
15.303(1)(b)that the system is not functioning in a mannerwhich 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 maash
Sns'3n 3 Trtie 5 Official Irspeotion F orm Subsurface Savage Disposal S)sWm•Page 3of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
S�Cccro Property Address S
I ✓I •
ON ner ON nees Name
information is
equQed for every
�a��r
b-3//
page. Qtyfrown State Zip Code Date of in pectic
B. Certifcation (coat.)
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 fleet 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. cOther.
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 Y2 day flow
t5ns-3M3 Titfe5Official InspecficnFartrz subswfacssewmeoisposal system,fte4of17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Se C L4$-I j,
Property Address
information is �IN
Owner Owner's Name
required for every 4 of�1(J /y O' 0"1*tJo —
B.page. Cityfrown State Zip Code Dat of nspec 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
❑ � 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 ivate water uPPIY wel
l.
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.
ElThe system fails I have determined that one or more of the above failure
criteria exist as described in 310 CM 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 fbilowing, 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.
tSns•3M 3 Title 5 Official Inspection F orm:subsufaw savage Disposal System•Page 5 of 17
C\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form, e Not for Voluntary Assessments
011
r Se.Guru
Property Address
Ow ner /✓1
infomlarmn is ;CINnel;smepagerequ.edforevery Page•
State Zip Code Date of lspection
C. ist
Check if the following have been done. You must indicate'yes"or"no"as to each of the following:
Yes p
❑ umping information was provided by the owner, occupant, or Board of Health
❑ Were any of the system components pumped out in the previous two weeks?
�o�.�athe system received nominal 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 WA)
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
n 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 3✓0
( p gpd x#of bedrooms):
LSns•3h 3
Title50f5ciai Inspectonfam[subwace sewmeDisposal S)mm•Page 60f 17
Commonwealth of Massachusetts
. .. .W Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
ON ner /
information is Q"ner's Name
required for every ✓I N r f /�/� �a 6 0 07-gh/
age' CtyRown State Zip Code Dale of Inspection
D. System nformation
Description: _
Number of current residents:
Does residence have a garbage grinder? ❑ Yes No
is laundry on a separate sewage system?(include laundry system inspection
information in this report.) ❑ Yes 0--90—
Laundry system inspected? ❑ Yes No
Seasonal use? E�esONo
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? Yes ❑ No
Last date of occupancy: C��r
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM R 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:
L5 ns-3H 3 Title sofficial Irspectim Form SubsWace Sem9e Disposal SWWm•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
to se C&4 vt
Property Address
Omm r �
Owner's Name
information is /
required for every q r PI r _ /� �o�V Q
page. Cityfrown cz State Zip Code Date of spectio
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 9--No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type
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 VA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other (descri be):
t5ms-3113 Me 6Official inspection F arm Suburfew Senage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
owner Owner's Name
information is
required for every q rt A r S ////7 !0 O/ a
page City/Town State Z' Code
Date of ns Y//A
pecti n
D. System Information (cons.)
Approximate age of all components, date instled i known) and source of information:
G� 'Co
Were sewage odors detected when arriving at the site? [] Yes NtJ` o
Building Sewer(locate on site plan):
Depth below grade:
_ feet
Material of construction:
❑ cast iron 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet /b
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Wank(locate on site plan): / ei
i
th below grad 0
feet
ria construction:
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
Dimensions:
Sludge depth:
t5ns•3M 3
Tlde5 Official lnspectionForm SutxWaeaSe ge)isposal System•Page9cf17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewagge'Disposal System Forgo -Not for Voluntary Assessments
(o �e � s
Property Address Gura
Ow ner
information is ""n'r- Name
required for every a✓l vt U / //� Qd 0
page. Cdy/Town State Zip Code Date—of coon
®e 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 recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
/l/n
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
t9ns•3113 Title 5omciai Irepec6cn Form substeace Sewage Disposal system•fte 10 cf 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Property Address
Ow ner ON ner's Name /✓1
requir at fo is ®l 6 01
requ�edforevery cf H f *OnspecWtion
rage. 'frownState Zip Code Dat
D. system information (coat.)
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 worldng order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attacti copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ns W3 Title5of5dalInspectionForm Subsuface Sewage Disposal SyVem•Page11 d17
is
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form "Not for Voluntary Assessments
to Se C u r c 4 ��
Property Address
ON ner � '
ON ner s Name
information is
required for every .q vl/I / 6 p oZ
page. City/Town ,4 State Zip Code Gate of fispecti6n
D. System Information (cont.)
Distribution Box (f present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 1_—V'e�-?
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.):
A1,5109(l ZZ- /
O / C�/
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:
15ins•313 Tille50fficlal Impeclion Form Subsurface Sew
age Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
kvtj 'L 6 C4 y-
Property Address
Owner
Ow nW; Name
infomrations ,
requ'vedforevery q►a 1�i7 oa 6 o/ a
page• C�ty/Town State Zp Code Date of
D. System nformation (cons.} p�t�
Type 9 soo
lT�i llo►� (i�a✓H �� �� f
❑ leaching pits number
❑ leaching chambers number.
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number-
0 innovativetaltemati%e system
Typetname of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
---------- Ll
�oVL-7
/I1V
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
tars-3M 3
riile50Fficial Inspection Fare[Subsurface Sewage Disposal S)Stem-Page 13 of 17
Commonwealth of Massachusetts
up
Title 5 Official Inspection
s
pacts®n Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
6 SeC�rb J Property Address
Ow ner
information is Ow s Nam
ner' e
required for every z;di,4 r t page- n
��
Cdy/Tow
Inspection o
D. System Information (coat.) State Zip Code Dat
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.):
19rs•3M 3
Tlte50fficial InspectionFomc Subsirface Sewage Disposal S)atem•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
o (; SeC�rr S�
Property Address
Ow ner I H
infornution is Owner's Name
required for every N✓J! Ue16 D�
page. Cy/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
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
J/1
Co�rzw
3 /
�rOR J-1-
14
Aj -- 3 � d- -33
Mr.•3113 Title 50ffidat Inspection Fame Sutsuface Savage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not fur Voluntary Assessments
Property Se C�
R r� S
ON ner 411 Pi
information is ;Ow*vnmrs Namerequ'vedforevery ad-�00/Page• wn State Zp Code MWoF1nspWfion
De System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
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)
Q-/Checked with logal Board of Health-explain:
14jo%
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
ti !�/1 C17 C-)a o1 ' /(/O
"QM kH C r— C/
IJ
O G� c.
.S 15
Cal/V (�
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3M 3 Title 5 Official Inspection F art[Suft0ace Sewage Disposal System-Page 16 of 17
Commonweafth of Massachusetts
Title 5 official Inspection Form
Subsurface sewage g Disposal System Forth-Not for Voluntary Assessments
J 2C Gt✓t s
Roperty Address
Owner Owner's one
infomation is
requiredforeve y GvI!/1 /�/9 �a 6� �q /Tg
page- �y/Tawn State zipCode Me6f tnsFe-r—
E. Report Completeness Checklist
2 inspection Summary:A, B, C, D, or E checked
LJ hasp Summary D(System Failure Criteria Applicable to All Systems)completed
em hbrmation—Estimated depot to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
tft-3n3 T-W50f W 1MPe0*nFam[SuhW=e S-ep0is-d System,Page 17 of 17
i
f
R
Commonwealth of Massachusetts v
Title 5 Official Inspection- Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 7-18-12
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.
A. General Information �.
1. Inspector: ,�..
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
', L Zip Code�, City/Tow n State
d 1-50$495-0905 S13971
t,.., Teleph`one Number License Number
yaw
Certification
�• ,,...,
L-1 certify Ah 11 have personally inspected the sewage disposal system at this address and that the
ti c-informatik4eported 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
7-18-12
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority:
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the.same or different conditions of use.
t5ins-11/10 t Title 5 Official Inspection Form: urface Sewage Disposal System-Page 1 of 17
r
Commonwealth of Massachusetts r
Title 5 Official .I nsp` ection, Form` .f
_ Subsurface Sewage,Disposal System,Form -Not for Voluntary Assessments :
. -
7M 6 Security St t
Property Address -- rs
Patricia Fahey
Owner Owner's Name r °
information is
required for every Hyannis a t MA 02601 7-18 12
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'Pa'sses:
® 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: }Y
t
System is in good working order with no sign of failure. .
B) System Conditionally Passes: 4 `
t F One,6r 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
w• •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. j
s
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
A inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally,sound,not leaking and,if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y 0. .N ❑ ND (Explain.below):
A
x;
t5ins•'11110 i- "m Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 17
Commonwealth of Massachusetts
_ s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 7-18-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to,broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order:to determine if
the system is failing to protect public health, safety or the environment.
1: System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t ❑ ' 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
. r -
N Commonwealth of Massachusetts if
Title 5 Official Inspection Form r
Subsurface Sewage Disposal System Form -Not forVoluntary Assessments
6 Security St T
Property Address
Patricia Fahey ;
Owner Owner's Name
information is required for every Hyannis r, MA 02601 7-18-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) f r
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: r
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water suppli 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 SA_S 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
P 9 9 4
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:
z
' 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
❑ Z. '' or clogged SAS or cesspool `
Liquid depth in cesspool is less than 6" below invert or available volume is less
❑ -® - than day flow f
t5ins-11110 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
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 7-18-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
- and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd:
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ the system is within 400 feet of a surface drinking watersupply
} ❑ ❑ the system is within 200 feet of a tributary to.a surface drinking water supply
❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
El Area— IWPA) or a mapped Zone II of a public water supply well
If'you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts .'
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments_,,,
G'M 6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is " ,•
required for every Hyannis t!. MA 02601 7-18=12
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes"or."no" as to each of the following:
Yes No ,
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
Z. ❑ Was the facility or dwelling inspected for signs.of sewage backup?
. , ,j . ,
- ® , ❑ ;Was the site inspected for signs of-break out?
®. ❑ :Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
' inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
Was the facility owner(and occupants if different from owner) provided with
® ❑ information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information `.
Residential Flow Conditions: r'
Number of bedrooms (design): 2 Number of bedrooms(actual): 2
x .. +DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
r * i
t5ins•11/10 , .. i Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
r
Commonwealth of Massachusetts
,N Title 5 Official Inspection Form
i� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a ..
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 7-18-12
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 7-2012
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-11110 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts -
Title 5 Official Inspection} Form `
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -
M 6 Security St `
Property Address
Patricia Fahey
Owner Owner's Name
information is
required for every Hyannis MA 02601 7-18-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Owner-pumped 4yrs ago
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:' : ' gallons +
How was quantity pumped determined?
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool -
❑ Overflow cesspool '
❑ Privy ,E
❑ 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): t '
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
- fi
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 7-18-12
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:
P ( )
1998
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 14"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.):
Good condition.
Septic Tank (locate on site plan):
Depth below grade: 8"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: 1500 gal
Sludge depth:
12"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form=Not for Voluntary Assessments
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is Hyannis MA 02601 7-18-12
required for every H y '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) t
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
1611
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.):f
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction: =
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
r
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 6 Security St.
Property Address
Patricia Fahey
Owner Owner's(dame
information is required for every Hyannis MA 02601 7-18-12
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):
y .. Dimensions:
Capacity:
_ gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is',copy attached? ,-,❑ Yes ❑ No
' t5ins•11/10. + ti s Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts ry
Title 5 OfficialI nspectioh-f orm
Subsurface Sewage Disposal System Form''-"Not for Voluntary Assessments ,4 A;_
,M 6 Security St
s
Property Address '.
Patricia Fahey
Owner Owner's Name yr,
information is
required for every Hyannis MA 02601 _ 7-18-12r
page. City[Town State Zip Code 'Date of,ln_spection
D. System Information (cont.),,
r
Distribution Boz if r, t 'must resen `be o tined locate.on site Ian
Depth of liquid level above outlet invert
'Comments (note if box is level and distribution to outlets equal,-any evidence off 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 chambers."'
Pump Chamber(locate on site plan):
Pumps in working order: '` ❑ Yes ❑ No
Alarms in working order: Y' .' _ ❑ Yes _ ❑ No
Comments (note condition of pump chamber, condition of pumps and'appurtenances, etc.):
a-
•
ti
Soil Absorption System SAS locate on site plan, excavation not required): ry
rp Sy (
If SAS not`located; explain why:
, t
t5ins-11f10 _ Y fide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Im Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 7-18-12
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits - number:
® leaching chambers number: 2-500's
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
r Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach chambers in good condition and empty at inspection with stain line at 6"of bottom of chamber.
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•11110 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts riff, :•; - ,
Title 5 Official Inspection-Form }.
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
6 Security St '
Property Address
Patricia Fahey
Owner Owner's Name
information is _
t
Hyannis MA - 02601 -
required for every y
7 18-12
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.):
1.4
t5ins•11110 . 'Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
I= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1, 6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 7-18-12
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
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
t
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M ' 6 Security St + t'
Property Address r
Patricia Fahey
Owner Owner's Name
information is Hyannis :' 3 MA 02601 7-18-12}, '
required for every H y '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar f
❑ Shallow wells r
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.Boa`rd 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:
Original design plans show no groundwater at 12.
9 9 P
r
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11110 0 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
im Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 7-18-12
page. CityFrown 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
g
Y
' • V - r
a
t5ins-11/10 ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
w
Commonwealth of Massachusetts
N W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 476 Putnam Ave
Property Address
David Mclellan
Owner Owner's Name
information is required for every Cotuit MA 02635 7-25-12
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.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr E
Company Address
E. Falmouth
MA 02536
City/Town State
Zip Code,,,,,
1-508-495-0905 S13971
Telephone Number License Number11J)
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
7-25-12
Inspector's Signature Date
The system inspector shall submit a copy'of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office.of the DEP.The original should be sent to the system,owner
and copies sent to the buyer; if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
w
I
Commonwealth of Massachusetts r
Title 5 Official Inspection Form f
Subsurface Sewage Disposal System Form Not for Voluntary Assessments "
M 476 Putnam Ave - 4�
Property Address
David Mclellan
Owner Owner's Name
information is required for every Cotuit. MA .02635 7-25-12
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): .
a
t5ins•1110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
L Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 476 Putnam Ave
Property Address
David Mclellan
Owner Owner's Name
information is required for every Cotuit MA 02635 7-25-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
w
❑ 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):
J,
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. fi
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:
El Cesspool or privy oot ri 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-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts ` . -
Title 5 Official Inspection Form , "-"
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 476 Putnam Ave > °f
Property Address F
David Mclellan _«
Owner
Owner's Name -
information is
N'
required for every
Cotuit MA 02635 7-25-12
page. Cityfrown State Zip Code Date of Inspection
B. Certification.(cont.) E
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". r
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
P rY
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: `
c t
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
El ® J. clogged SAS or cesspool
❑ ' ® , Discharge or ponding of effluent to the surface of,the ground or surface waters
due to an overloaded or clogged SAS or cesspool -"
'El F Static liquid level in the distribution box above outlet invert due to an overloaded
rt. ..or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
❑' ® than Y2 day flow '
t5ins•11,110 ,. Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
w F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
476 Putnam Ave
Property Address
David Mclellan
Owner Owner's Name
information is required for every Cotuit MA 02635 7-25-12
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy,is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy,is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody_must be attached to this form.]
❑ ,® The system is a cesspool serving a facility with a design,flow of 2000gpd-
10,000gpd.
El ® 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
F El El Area
system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
!t
/
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
M 476 Putnam Ave
Property Address ,
David Mdellan r `'
Owner Owner's Name
information is required for every Cotuit MA 02635 7-25-12
-
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"non as to each of the following:
Yes No
® ,❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ . , ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
_ Were as built plans of the system obtained and examined? (If they were not
` El' 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?
® El .` `Were all system components, excluding the SAS, located on site?
® ❑ ' Were the septic tank manholes uncovered, opened, and the interior of the tank
j 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: F ,'
r Number of bedrooms (design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203.(for example: 110 gpd x#of bedrooms): 220
ou
t5ins•11!10 t 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
476 Putnam Ave
Property Address
David Mclellan ;
Owner Owner's Name
information is required for every. Cotuit MA 02635 7-25-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes'® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes E No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ® Yes ❑ No ,
Watermeter readings, if available (last 2 years usage (gpd)):
Detail:
•
r _ x
Sump pump? ❑ Yes ® No
7-2012
Last date of occupancy: ; Date
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? t ❑ Yes ❑ No
F
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,•if available:
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 476 Putnam Ave
Property Address
David Mclellan t
Owner Owner's Name k .
information is Cotuit MA 02635 7-25-12`
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
- Y,L •R
Last date of occupancy/use: - Date
Other(describe below):
General Information.- t
Pumping.Records;
Source of information: Owner--pumped 3yrs ago
Was system pumped as part of the inspection? - ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:: Maintenance
Type of System: .' t
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ OverFlow cesspool
❑ Privy
❑: - Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator.under contract
❑ - .,Tight tank.Attach a copy of the DEP approval'
❑ Other(describe):
t5ins-11.'10 m Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
✓ Commonwealth of Massachusetts
m W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 476 Putnam Ave
Property Address
David Mclellan
Owner Owner's Name
information is
required for eve Cotuit MA 02635 7-25-12
9 every
City/Town/Town State Zip Code Date of Inspection
page. Y P P
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2002
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 32"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.):.
Good condition.
5 .
Septic Tank(locate on site plan):
Depth below grade: 24"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: 1500 gal
Sludge depth:
10"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments'
�b 476 Putnam Ave
Property Address
David Mclellan
Owner Owner's Name
information is required for every Cotuit MA 02635 7-25-12
page. City/Town State Zip Code s Date of Inspection
D. System Information (cont.) -
'
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
22"
Scum thickness -
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 '
16"
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.): F
Tank is in good condition with baffles installed and no sign of leakage.-'
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: bate
t5ins•1110 • Title 5 Official Inspection Form'Subsurface Sewage Disposal System-Page 10 of 17
✓ Commonwealth of Massachusetts
m W Title 5 Official Inspection Form
Im Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
476 Putnam Ave
Property Address
David Mclellan
Owner Owner's Name
information is required for every Cotuit MA 02635 7-25-12
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.): y
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-11l10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts _
Title 5 Official Inspection Form
Subsurface Sewage Disposal'System Form-Not for Voluntary Assessments
476 Putnam Ave
Property Address
David Mclellan .
Owner Owner's Name f
information is required for every Cotuit MA 02635 7-25-12
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.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes_ ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•11,10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 476 Putnam Ave
Property Address
David Mclellan
Owner Owner's Name
information is required for every Cotuit MA 02635 7-25-12
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: 1-30'x15'
❑ 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.):
Leach field in good condition wit no sign of back-up into d-box or surrounding stone.
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-11110 Title 5 Official Irispection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form!
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
476 Putnam Ave
Property Address
David Mclellan
Owner Owner's Name
information is Cotuit MA 02635 7-25-12
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of,ponding, condition of vegetation,
etc.):
E• a ,
Privy (locate on site plan):
Materials of construction:
Dimensions 3
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11M0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
I= W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments_
476 Putnam Ave
Property Address
David Mclellan
Owner Owner's Name
information is required for every Cotuit MA 02635 7-25-12
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
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
Y � �
10
1 Ca
i
V
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form-_
Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
••f4 476 Putnam Ave
Property Address -
David Mclellan rt
Owner Owner's Name
information is '
required for every 'Cotuit MA 02635 7-25 12 '
page. City/Town •" State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope r
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
feet
Please indicate all methods used to determine the high groundwater 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:
Original design plans show no groundwater at 12'.
Before filing,this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
,= Title 5 Official Inspection Form
x
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 476 Putnam Ave
Property Address
David Mclellan
Owner Owner's Name
information is required for every Cotuit MA 02635 7-25-12
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
t
t '
• A
i r
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
l U�-�J ✓f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 6-1-10
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.
A. General Information
1. Inspector:
I
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
"E. Falmouth MA 02536
City/Town State Zip Code
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 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-3-10
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000. gpd or greater,:the inspector and the system owner.shall submit the.
report to:the appropriate regional office of the DEP. The original should be sent.to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
I �
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface S age Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 6-1-10
page. CitylTown 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.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined, please explain.
❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
* A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old'is'available.
ND Explain:
I
❑ 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
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 6-1-10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
C) Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a.surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 6-1-10
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems: ,
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® 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
El ® 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.
t5insp official document•03108 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 6-1-10 .
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® 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
El El the system is within 200 feet of.a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
❑ El
Area-IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Security St
Property Address
P Y
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 6-1-10
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes"or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑' Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this.inspection? I . . ,
Were as built plans of the system obtained and examined? (If they were not
available note as NIA)
® ❑ Y 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 materi
al ial 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)]
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 6-1-10
page. City/Town State Zip Code Date of Inspection
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
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 6-1-10
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments:
�M 6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is H
required for every y annis MA 02601 6-1-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Owner--pumped 2 yrs ago
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
Type of System:
® 'Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) 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):
Approximate age of all components, date installed (if known) and source of information:
1998
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 6-1-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 14"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.):
Good condition.
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
y
__________________________________________________________________________________________________________________________
Dimensions: 1500 gal
Sludge depth:
16"
Distance.from top of sludge to bottom of outlet tee or baffle
16"
Scum thickness
2"
Distance from top of scum to..top of outlet tee or baffle
5".
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is Hyannis MA 02601 6-1-10' .
required for every y
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.):
Tank is in good condition with baffles installed and no sign of leakage.
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
a
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.):
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):
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 6-1-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 6-1-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: 2-500's
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number.
❑ innovative/alternative system
Type/name of technology:
Comments note condition of soil signs of hydraulic failure level of ondin dam soil condition of
( � 9 Y � P 9� P
vegetation, etc.):
Leach chambers in good condition and holding 6" of water at inspection with no visible stain lines.
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 6-1-10
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp official document•03108 TrUe 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is required for every Hyannis MA 02601 6-1-10 '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sk
etch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including tees
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building:
• C
4
f
a e
A —0— 3 '' - - 3g
3
14- 8t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i
6 Security St
Property Address
Patricia Fahey
Owner Owner's Name
information is Hyannis MA 02601 6-1-10
required for every H y �
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 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:
Original design plans on file show no groundwater at 12'.
6}
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
i 6a
r