HomeMy WebLinkAbout0042 SILVER LANE - Health 42 SILVLR LANE, HY.ANNIS
A= 268 155
I
a
i
o
k
f�
c Commonwealth of Massachusetts LQ6P8-4c�1s_
:. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Silver Lane
Property Address . + -
e: t
Anon elo & Mary Delio r
_....---.....
Owner
Owner's Name
information is Hyannis MA 02601 6-25-20
required for every —_ --- -- -- --
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
`1'1�%1tu111111111111
OF lu1iq
Important:When filling out forms A. Inspector Information Q* /z/_0 6/- ,�'°�• s9 '''--
� O=• cyG
on the computer, ?g: JAMES
use only the tab
James D.Sears _�: SEARS
key to move your Name of Inspector T� = -'
cursor do not Robert B. Our Co.INC A o 0
use the return -- - - --
key. Company Name �r,� ..5.TI....�GC\``\o�.
363 Whites Path _ ���� Nsp0\'N
r� Company Address
South Yarmouth_ MA 02664 _
City/Town State Zip Code
r � 508-477-8877 S1623
Telephone Number License Number
B. Certification J
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);.1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
_ r's Signature �_`f 6-25-20 _
1 cto Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
42 Silver Lane
V
Property Address
Angelo & Mary Delio
Owner Owner's Name
information is Hyannis MA 02601 6-25-20
required for every y _ _. —
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System Pass. The system is a 1000 Gal. Tank andQt:
2) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc-rev.712512010 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 16
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
r1I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
42 Silver Lane
Property Address
Angelo & Mary Delio _ ......
Owner Owner's Name
information is Hyannis MA 02601 6-25-20
required for every y —
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t6m.p.doc•rem.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage DispOS21 SySlem-Page 3 Of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
`I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.......... 42 Silver Lane
Property Address
Angelo & Maw Delio _
Owner Owner's Name
information is Hyannis MA 02601 6-25-20
required for every y _ .. __ __.
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
El ® 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
c � Commonwealth of Massachusetts
Title 5 Official Inspection Form
I? I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
<, 42 Silver Lane
Property Address
Angelo& Mary Delio _ J_
Owner Owner's Name
information is Hyannis MA 02601 6-25-20
required for every y -_..
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ❑ . Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in is less than 6" below invert or available volume is less
than '/day flow 1"/T'
❑ ® 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 water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
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 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Silver Lane
Property Address
Angelo & Mary Delio
Owner Owner's Name
information is required for every Hyannis MA 02601 6-25-20
—� - —
page. City/Town State Zip Code Date-of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes" to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system Components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/261201B Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18
I -
Commonwealth of Massachusetts
�- T. Title 5 Official Inspection Form
ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
42 Silver Lane
Property Address
Angelo& Mary Delio
Owner Owner's Name
information is Hyannis MA 02601 6-25-20
required for every _ -- _.
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): NA Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
1000 Gal. Tank and pit.
2
Number of current residents: -
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d na
9 ( Y 9 (gp ))�
Detail:
Sump pump? ❑ Yes ® No
Present
Last date of occupancy: pate
l5insp.doc•rev.7/2 612 01 8 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
f
c Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
fo;, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Y
42 Silver Lane
Property Address
Angelo & Mary Delio
Owner Owner's Name
information is Hyannis MA 02601 6-25-20
required for every --.--------.---.-----
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): -
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available: -
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information: 8-2019
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined? — -
Reason for pumping:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 8 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
1 <1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
!% 42 Silver Lane
Property Address
Angelo & Mary Delio _
Owner Owner's Name
information is required for every H annis MA 02601 6-25-20
--y --- --
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the 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:
NA _
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain): —
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH -40.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Fri, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
42 Silver Lane
Property Address
Angelo& Mary Delio
Owner Owner's Name
information is required for every Hyannis MA 02601 6-25-20
- - --- ----
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
14" _
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
1000 Gal. Precast H-10 _
Dimensions:
2" _
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
28"
oilScum thickness -
12"
Distance from top of scum to top of outlet tee or baffle -
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt-Tape
Sludge Judge
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 at working level. Tank and covers at 14". Inlet w/outlet baffle. No sign of leakage or over
loading. --
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
r
C Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Silver Lane
Property Address
Angelo& Mary Delio
Owner Owner's Name
information is required for every Hyannis MA 02601 6-25-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness -
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle — �-
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gauons
Design Flow: gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
42 Silver Lane
Property Address
Angelo & Mary Delio _
Owner Owner's Name
information is H annis MA 02601 6-25-20
required for every Y - ---
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: - -- Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
" Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
no box
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.):
I
t5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
ct Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e � 42 Silver Lane
Property Address
Angelo & Mary Delio
Owner Owner's Name
information is Hyannis MA 02601 6.25-20
required for every y -- --- -- -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No`
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
" If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
1
® leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: ---
t5insp.doc•rev.7/26/2016 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•rage 13 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
42 Silver Lane
V
Property Address
Angelo & Mary Delio
Owner Owner's Name
information is Hyannis MA 02601 6-25-20
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is a 1000 Gal. precast pit. Pit and cover at 1' below grade. 2'water in pit w/no high stain
line. No sign of over loading or solid carry over.
12. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
`..............c, ,,. 42 Silver Lane
u-
Property Address
Angelo& Mary Delio
Owner Owner's Name
information is Hyannis MA 02601 6-25-20
required for every y —
page. Citylfown State Zip Code Date of inspection
D. System Information (cont.)
13. Privy (locate on site plan):
Materials of construction: ---
Dimensions -- --
Depth of solids ��----
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
42 Silver Lane
V
Property Address
Angelo & Mary Delio
Owner Owner's Name
information is
required for every Hyannis MA 02601 6-25-20
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
N,
O �
Qe
3 d i
Z. 3'
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
1
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
42 Silver Lane
Property Address
Angelo & Mary Delio
Owner Owner's Name
information is Hyannis MA 02601 6-25-20
required for every y — --
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
O
Estimated depth to high ground water: 1 —
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:
CK A Butting area 12' no G.W..
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
l� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
42 Silver Lane
Property Address
Angelo & Mary Delio
Owner Owner's Name
information is Hyannis MA 02601 6-25-20
required for every -------- --- - —
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank— Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
Pi 7- J-1
t5insp.doc•rev.7/26/201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
A
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection NOV 2 4 1995
HMTM DEc
William F.Weld 'row QF OMINvr.�T BILE
Governor
Trudy Co"
0 Secretary,EOEA
!� David B.Struhs
CommhWoner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
S r Ole r PART A
/,S CERTIFICATION
Property Address: _ �� Address of*Owner:
Date of Inspection: �-a (if different)
Name of Inspector: W.E. Robinson Sr.
Company Name, Address and Telephone Number: W.E. Robinson Septic Service
P.O. Box 1089
Centerville MA
CERTIFICATION STATEMENT ��7 --77��77
I certify that I have personally inspected the sewage disposl s�sCerh�t this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
_ Fails
Inspector's Signature: 6"1 d�ti...._._� � Date: 9
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30)days of completing this
inspection. If the system is a shared system or has a design flow of 10,000.gpd or greater, the inspector and the system owner shall subrrtit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] SYS PASSES:
1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more syste components need to be replaced or repaired. The system, upon completion of the.replacement or repair,
passes inspection.
Indicate yes, no, or not determ ned (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septic nk is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved y e Board of Health.
(revised 8/15/95) 1
One Winter Street • Boston,Massachusetts 02108 • FAX(617)SW1049 • Telephone(617)292-5500
tQ Printed on Recycled Paper
t
.i4
�� ��
__
_ .
�-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
/ CERTIFICATION (continued)
Property Address:
Owner: k3✓'.g CJ S h A 4J
Date of Inspection:
B) SYSTEM CONDITIONALLY PASSES (continued)
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
ipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
B and of Health):
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
_ Th system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
i pection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C) FURTHER EVALUATION REQUIRED BY THE BOARD OF HEALTH:
Conditions exist whi h require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety nd the environment. "
1) SYSTEM WILL PASS NLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTE THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or pri is within 50 feet of a surface water
Cesspool or priv is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLE S THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIO ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
_ The system has a s pnc tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water suppl
_ The sv� tem has a se tic tank and soil absorption system and is within a Zone I of a public water supply well.
_ The system has a se is tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a se tic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well, unless well water analysis for coliform bacteria and volatile organic compounds indicates that the well is ,
free from pollutio from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
D) SYSTEM FAILS:
I have determined that the syste violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identifii below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage in o facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or pon of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
(revised 8/15/95) 2
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued),
lve �n -e-
Property Address: �� �� / ` Y
Owner:
Date of Inspection:
D)SYSTEM FAILS(continued):
tatic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Li uid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Req 'red pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Num r of times pumped
Any p rtion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any p ion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any po ion of a cesspool or privy is within a Zone I of.a public well.
Any po ion of a cesspool or privy is within 50 feet of a private water supply well.
_ Any rtion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acc ble water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following triter a apply to large systems in addition to the criteria above:
The design flow system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environmen ecause one or more of the following conditions exist:
the system is ithin 400 feet of a surface drinking water supply
the system is ithin 200 feet of a tributary to a surface drinking water supply
the system.i located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public w supply well)
The owner or operator of any s ch system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.0 an 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner: f� c� /,4
Date of Inspection:
Check if the following have been done:
11
mping information was requested of the owner, occupant, and Board of Health.
VNone of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
1 duringAs,built plans have been obtained and examined'. y during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
v d. Note if the are not available with N/A.
_/ min e
1/The facility or dwelling was inspected for signs of sewage back-up.
,/The system does not receive non-sanitary or industrial waste flow
�e site was inspected for signs of breakout.
_✓All.system components, excluding the Soil Absorption System, have been located on the site.
he septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles.or
tees; material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
_The size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
_i.Zhe facility o%Nner (and occupants, if different from owner) were provided with in on the proper maintenance of Sub-
Surface Disposal System.
> r
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: c�— s/ U e 14 fi
Owner: K . )3✓'AV 6 i7,,�7U
Date of Inspection:
FLOW CONDITIONS °
RESIDENTIAL:
Design flow:_a3 Q gallons
Number of bedrooms: -3
Number of current residents:
Garbage grinder(yes or no): J .
Laundry connected to system (yes or no):Y--
Seasonal use (yes or no):_)I."
Water meter readings, if available:
Last date of occupancy:I^I td-q
COMMERCIAUINDUSTRIAL:
Type of establish ent:
Design flow: allons/day
Grease trap present: yes or no)_
Industrial Waste Hol ing Tank present: (yes or no)_
Non-sanitary waste d scharged to the Title 5 system: (yes or no)_
Water meter reading , if available:
Last date of occu ncy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
A
System pumped as part of inspection: (yes or no)_
If yes, volume pumped. gallons
Reason for pumping:
TYPE QI SYSTEM
P Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other(explain)
ol� s
APPROXIMATE AGE of all components, date installed (if known) and source of information: S
Sewage odors detected when,arriving at the site: (yes or no)At,"
5
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 4-1c)—
Owner: I��` O c5 h 9
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
E �
Depth below grade: 10
Material of construction: _concrete metal FRP other(explain)
- 0 l� l
Dimensions: _k Ar
Sludge depth: 0 ,
Distance from top of sludge to bottom of outlet tee.or baffle: 0
Scum thickness:
E
Distance from top of scum to top of outlet tee or baffle: t 4'
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.) i.0 1L/� C l A Y+-���'f µ— p 'e j i
GREASE TRA a
(locate on site p n)
Depth below grad
Material of constru 'on: _concrete _metal _FRP—other(explain)
Dimensions:
Scum thickness:
Distance from top of s um to top of outlet tee or baffle:
Distance from bottom t From t� hOttom Ot OL let tee or baffle:
Comments:
(recommendation for umping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence a age, etc.)
(revised 8/15/95) - 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: L/ s i �//C/ /-,,Ih e--
Owner:
Date of Inspection:
TIGHT OR" LDING TANK:_
(locate on site an
Depth below grad
Material of constru 'on: _concrete _metal _FRP—other(explain)
Dimensions:
Capacity: gallons
Design flow: allons/day
Alarm level:
Comments:
(condition of inlet tee condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above o tlet invert:
Comments:
(note if level and distributiur, s equal, e\idence of solids cam o•,cr, evidence of leakage into or out of box, etc.)
PUMP CHAMBER:_
(locate on site plan)
Pumps in working order.(yes or n )
Comments:
(note condition of pump chamber, ondition of pumps and appurtenances, etc.)
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: 6r'5'-0 Sd7'9 u�')
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):_
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (note condition of soil, si ns of hydraulic failure, level of ponding, condition of vegetation,etc.)
/ fCi ® � fQd RrGt► �I Star 1
p,0
c4t,
CESSPOOLS:
(locate on site pla
Number and configur ion:
Depth-top of liquid to i let invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of constructio
Indication of groundwa er:
inflow (cessp of must be pumped as part of inspection)
Comments: (note condition o soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
f
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.)
Irevised 8/15/95) 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: f}
Date of In
spection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
;L LJ
DEPTH TO GROUNDWATER
Depth to groundwater:_L2=__feet
method of determination or approximation: to d ,45
(revised 8/15/95) 9
TOWN OF BARNSTABLE
I
LOCATION L/ ,S� `/„ ��� 1. A SEWAGE #
VILLAGE ASSESSOR'S MAP LOT
,�Pa.6 Pe
INSTALLER'S NAME 6i PHONE NO. y` j �d o r" 7 7 'SS 9 -7 4
SEPTIC TANK CAPACITY / C G—0
LEACHING FACILITY:(type) 10 -0 G (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
r
l
J
..o
a