HomeMy WebLinkAbout0063 SMITH STREET - Health 6 Smith Street, .Hyannis
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Commonwealth of Massachusetts ag8- c)ate"
41 UJVjr7j Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Smith Street
Property Address
Carol Montana
Owner Owner's Name
information is H annis t/ Ma_...-_ 02601 7/15/2020
required for every
pap. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:when A. Inspector Information 5I4F HbOV
filling out forms
on the computer, Sean M. Jon@S
use only the tab ..
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection
usethe return .__. ._.. ..____._�._..................._..................._._._._....�..__
key. Company Name
74 Beldan Lane
� Company Address
Centerville Ma 02632
- City(rown State �� � Zip Code
774-248-4850 smjonestitle5 e@gmaii.com, SI 4522
seanQsmonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 16.000); 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. M Passes
2, ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
7/15/2020
_ n..__ .__ _ .__ .......
Inspector's.Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board;.
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional,office of the DEP. The original 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.
t5mp.toc-rev.MOW Title 5 Official insertion Form:Subsurface Sewage Disposal System-Page f of 10
Commonwealth of+Massachusetts
Title 5 official Inspection. Form
- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
p 63 Smith Street
Property Address
Carol Montana
Owner owner's Name
information is H annis Ma 02601 7/15/2020
requiredfor every _ _. -...__................___-.--._.......-_...._.._..._._...-_.------....._
page. CItylTown 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:7-' c'
® 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:
The property located at 63 Smith St Hyannis is served by a Title V septic system consisting of a 1500
gallon septic tank, distribution box and 7 Infiltrators. Although the system was found to be in proper
working condition at the time of inspection this report does not guarantee future performance under
similar or increased usage.
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):
t5lnspAcc•rev.712612018 five 5 Offinia!Ingpeclion Form Subsurface Sewage Disposal SYstem•Pago 2 of 18
;e Commonwealth of Massachusetts
Title 5 Official Inspection Farm
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
? a .63 Smith Street
Property Address
Carol Montana
Owner Owner's Name
information is H annis__ Ma 02601 _ 7/15/2020
required for every Y—_ _ _. _. _ ,... ...__.. M
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):
_.._._.._____._____..................................... .............. m..,_., ......... . .......
The system required pumping more than 4 times a year due to broken r r❑ o obstructed i e s . The
Y q P P 9 Y PP { )
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 M 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 le not functioning in a manner which will protect public health,
safety and the environment:
1511SP.dae rev,M612018 Titta 5 Mcial Inspection Form Subsurfaea Sewage Disposal System-Page 3 of IS
Commonwealth of Massachusetts
_- Title 5 Official Inspection Form
_
µ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Smith Street
Property Address
Carol Montana
Owner Owner's Name
information is Hyannis Ma 02601 7/15/2020
required for every Y . . ..._ _ �-----�.-
p�- Cityrrown State Zip Code Date of In_spectio__n
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
❑ ® 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
t56ssp.doe-rev.712WO18 Title 5 Ogidal Inspection Farm Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Smith Street Property Address
Carol Montana
Owner owner's Name
information is H annis Ma 02601 7/15/2020
required for every ... ._._._.___.�— _ _
-----
PaW City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (coot.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or cogged SAS l cesspool
S or
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
Required pumping more than 4 times in the last year NOT due to clogged or
El ® 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.
El ❑ 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
1 kw,doc•rev,MOM Title 5 official inspection Form Subsurface Sewage Disposal System-Page 5 of 18
Commonwealth of Massachusetts
=i Title 5 Official Inspection Form w
I;) Subsurface Sewage Disposal System Form Not for Voluntary Assessments
63 Smith Street
Property Address
Carol Montana
Owner Owner's Name
Information Is H_ya_n_nis_
page. Ma 02601 7/15/2_020
for every CityfTown y State Zip Code Date of Inspection
P�3
C. Inspection Summary (cont.)
If you have answered"yes" to any question in Section C.5 the system is considered a significant
"yes"to an question in Section CA above the large system has failed. The
threat, or answeredy y q 9 Y
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgradeY
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)]
t6insp.doc•rev 712612018 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page a of IS
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r _ - q Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
Y
s
63 Smith Street
` Property Address
Carol Montana
Owner Owner's Name
information is H annis Ma 02601 7/15/2020
required for every y.... _ .._ _ _ v._... _�.,, ... .,...W.v_ _
per. CitylTown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions: _
Number of bedrooms(design): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd
Description:
Number of current residents: 2
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 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp,doc•r®v-.712612018 Tate 5 otfio+al trlspeol iott Form:Subsudace Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official ,Inspection Form y
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
-> 63 Smith Street
Property Address
Carol Montana
Owner Owner's Name
information is H annis Ma 02601 7/15l2020
required for every —�__,_....._.._-. -
page Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
Type of Establishment: - -
i
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: —- -
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: -
15inaP.doc-rev.7128f2016 Title 5 Official tnspecuon Form.Subsurface Sewage Disposal System-Page 8 of 18
}
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Smith Street
Property Address —
Carol Montana
Owner Owner's Name -
information is required for every H annis Ma 02601 7/15/2020
��
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool.
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the UA 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:
system installed 2/27/1998
Were sewage odors detected when arriving at the site? ❑ Yes No
5. Building Sewer(locate on site plan):
Depth below grade: 15
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.):
Joints in good condition, no leakage, vented through roof.
t5insp.doc•rev.7126/2018 Tide 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 18
e� Commonwealth of Massachusetts
Title 5 Official Inspection Form
- - i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Smith Street
Property Address
Carol Montana _
Owner Owner's Name
information is Hyannis Ma 02601 7/15/2020
required for every y _._
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gallons
5"
Sludge depth: _._.._...._.
Distance from top of sludge to bottom of outlet tee or baffle 3' — ----- -- -
Scum thickness 2
Distance from top of scum to top of outlet teP or haffle 711
- --- - --- ......-...
_
Distance from bottom of scum to bottom of outlet tee or baffle 10" ------
How were dimensions determined? Opened covers and took
measurements
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 does not need to be cleaned now but should be done soon and again every 2 years for proper
maintenance. water level was even with outlet, tank was not leaking and was structurally sound.
t5insp.doc•rev,7126/2018 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 10 of 18
, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Smith Street
Property Address
Carol Montana
Owner Owner's Name
information is Hyannis Ma 02601 7/15/2020 „
required for every _ _. __.,....... .__._-_-..._..
,
page, Clty/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feel
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: gallons
Design Flow: gallons per day
tbinsp.dw•rev.7/26/2018 Title 5 Official Inspection Forth Subsurface Sewage Disposal System Page t t of III
Commonwealth of Massachusetts
f = Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Smith Street _
Property Address
Carol Montana
Owner Owner's Name -
information is H_ anrns Ma 02601 7/15/2020
required for every _. __._�_.._.___-. --_
page. CItyrrown State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cunt_)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: 11 t®___.__...................._..
oa
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):
0"
Depth of liquid level above outlet invert ---- — -
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box was video inspected and found level and in good condition with no rot. Water level
was even with outlet Invert with no signs of past backup.
15hsp doc•rev 7126/2018 Title 5 official Inspection Farm Subsurface Sewage Dsposel System•Page 12 of 18
Commonwealth of Massachusetts
r : - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Farm Not for Voluntary Assessments
63 Smith Street
Property Address
Carol Montana _
Owner Owner's Name
information is
e
required for every H annis Ma 02601 . 7/15/2020
�_�____..__ .____. _
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No`
Alarms in working order: ❑ Yes ❑ Now
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:
❑ leaching pits number:
® leaching chambers number: 7 Infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions: ...... —---
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
15insp.doc•rev.7126n018 titla 5 pflicial Inspection Form Sutasurfaca Sewapa Disposal System•Page 9018
Commonwealth of Massachusetts t
Title 5 Official Inspection Form
_ == Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Smith Street
- Property Address
Carol Montana _
Owner owner's Name
information is H annis Ma 02601 7/15/2020
required for every __y_____._... __.._.__..... __ .. _ . —
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
leaching facility was video inspected from vent and was found dry with no signs of past overloading
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 _e---------. __...._____._._______.._.._........_ ..._.---...
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.):
l5insF.doc•rev.712612ti18 Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 1a of 18
Commonwealth of Massachusetts
rivTitle 5 Official Inspection Form
r} Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Smith Street
Property Address
Carol Montana
Owner Owner's Name
information is H required for every anrns Ma 02601 7/15/2020
�_._____ -_
page. City/Town State Zip Code_ Date of Inspection ��
D. System Information (cant.)
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.):
tSinsp.doc•rev.7lZ MIS Title$official Inspection Forth:Subsurface Sewage Disposal System-Page 15 of 19
.^"I Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
63 Smith Street
Property Address
Carol Montana
Owner Owner's Name
information is H annis Ma 02601 7/15/2020
required for eve
_. —
q every Cityrrown ��� State Zip Code Date of Inspection
page.
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
R Y
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
Al 2 I
6( y'7
A 2,0 o f
L C. - 3 2?
D� �y
cIf 33
t5insp.doc•rev.7f Q018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
el` Commonwealth of Massachusetts
tY - ' Title 5 Official Inspection Form
-- I Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
. , - 63 Smith Street
Property Address
Carol Montana
Owner Owner's Name
information is Hyannis
Ma 02601 7/15/2020
required for every _
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cunt.)
15. 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 160 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
Cl Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater was established by accessing town of Barnstable groundwater contour maps.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Fong Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Officia Inspection Form
: . t Subsurface Sewage Disposal System Form• Not for Voluntary Assessments
i..
63 Smith Street
Property Address
Carol Montana
Owner Owner's Name
information Is required for every Hyannis Ma 02601 7/15/2020
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6 (Checklist)completed
® D. System Information:
For S:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/2812018 Title 5 ORual Inspedion Form Subsurface Sewage Disposal System•Page t8 of 18
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY fA'
Owner Owner's Name —'
information is
required for every HYANNIS ✓ MA 02601 08/24/2015 =
page. City/Town State Zip Code Date of Inspection N
Inspection results must be submitted on this form. Inspection forms may not be altered in any mr'
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer, //Q 97
use only the tab 1. Inspector: / /
key to move your
cursor-do not JOHN P GRACI SR '
use the return Name of Inspector
key.
GRACI SEPTIC INSPECTIONS LLC
,y Company Name
PO BOX 2119
Company Address
TEATICKET MA 02649
City/Town State Zip Code
508-641-6694 S 1468
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 E aluation by the Local Approving Authority
08/24/2015
Inspector's Signature Date
The system inspector all submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)with 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.
VIS
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is required for every HYANNIS MA 02601 08/24/2015
,
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:
® 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:
AT THE TIME OF INSPECTION SYSTEM APPEARS TO BE STRUCTUARLLY SOUND AND
FUNCTIONING PROPERLY. RECOMMEND NOT DRIVING ON SYSTEM. RECOMMEND
PUMPING EVERY TWO YEARS . RECOMMEND RAISING DISTRIBUTION BOX COVER.
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):
NA.
i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is required for every HYANNIS MA 02601 08/24/2015
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
NA
❑ 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):
NA
C) Further.Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
.t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is required for every HYANNIS MA 02601 08/24/2015
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a 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: NA
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
NA
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 1/2 day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is required for every HYANNIS MA 02601 08/24/2015
page. CitylTown 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 water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is required for every HYANNIS MA 02601 08/24/2015
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)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 4 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
l� Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is required for every HYANNIS MA 02601 08/24/2015
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
1500 GALLON SEPTIC TANK DISTRIBUTION BOX AND 7 INFILTRATORS
Number of current residents: VACANT
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes .® No
Water meter readings, if available last 2 ears usage d TOWN
9 ( Y 9 (gP ))�
Detail:
2013 -3900 CUBIC FEET 2014- 5000 CUBIC FEET
Sump pump? ❑ Yes ® No
Last date of occupancy: VACANT
Date
Commercial/Industrial Flow Conditions:
Type of Establishment: NA
Design flow(based on 310 CMR 15.203): NAGallons per day(gpa)
Basis of design flow(seats/persons/sq.ft., etc.): NA
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: NA
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° M 63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is HYANNIS MA 02601 08/24/2015
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: NA
Date
Other(describe below):
NA
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: NA
gallons
How was quantity pumped determined? NA
Reason for pumping: NA
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):
NA
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is required for every HYANNIS MA 02601 08/24/2015
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:
1998
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: (3) THREE FEET
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: GREATER THAN 10+ FEET
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT
TIME OF INSPECTION.
Septic Tank (locate on site plan):
Depth below grade: 37 INCHES
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
SEPTIC TANK APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT
TIME OF INSPECTION RECOMMEND PUMPING EVERY TWO YEARS
If tank is metal, list age: NA
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: STANDARD 1500 GALLON
Sludge depth: (6) SIX INCHES
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�.0 63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is required for every HYANNIS MA 02601 08/24/2015
page. CityFrown State Zip Code Date of Inspection
D. System Information (cost.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle (28)TWENTY EIGHT INCHES
Scum thickness (2)TWO INCHES
Distance from top of scum to top of outlet tee or baffle (6) SIX INCHES
Distance from bottom of scum to bottom of outlet tee or baffle ZERO
How were dimensions determined? MEASURED
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500 GALLON SEPTIC TANK APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING
PROPERLY AT TIME OF INSPECTION RECOMMEND PUMPING EVERY TWO YEARS.
Grease Trap (locate on site plan):
Depth below grade: NA
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
NA
Dimensions: NA
Scum thickness NA
Distance from top of scum to top of outlet tee or baffle NA
Distance from bottom of scum to bottom of outlet tee or baffle NA
Date of last pumping: NA
Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -. Not for Voluntary Assessments
63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is required for every HYANNIS MA 02601 08/24/2015
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.):
NA
n .
Tight or Holding Tank tank must be pumped at time of inspection) (locate on site plan)..
g 9 ( P p
Depth below grade: NA
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
NA
Dimensions: NA
Capacity: NAgallons
NA
Design Flow: gallons per day F
Alarm present: ❑ Yes ❑ No
Alarm level: NA Alarm in working order: ❑ Yes ❑. No
Date of last pumping: NA
Date
Comments (condition of alarm and float switches, etc.):
NA
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is required for every HYANNIS MA 02601 08/24/2015
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 BOTTOM OF PIPE
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
DISTRIBUTION BOX APPEARS TO BE STRUCTUARLLY SOUND AND FUNCTIONING
PROPERLY AT TIME OF INSPECTION. RECOMMEND RAISING COVERS
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.):
NA
* 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:
NA
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is required for every HYANNIS MA 02601 08/24/2015
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 7
❑ 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 ponding, damp soil, condition of
vegetation, etc.):
7 INFILTRATORS APPEAR TO BE STRUCTUARLLY SOUND AND FUNCTIONING PROPERLY AT
TIME OF INSPECTION RECOMMEND NOT DRIVING OVER SYSTEM
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration NA
Depth —top of liquid to inlet invert NA
Depth of solids layer NA
Depth of scum layer NA
Dimensions of cesspool NA
Materials of construction NA
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection 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
wM 63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is required for every HYANNIS MA 02601 08/24/2015
page. Cityrrown 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.):
NA
Privy (locate on site plan):
Materials of construction: NA
Dimensions NA
Depth of solids NA
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
NA
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, 63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owners Name
information is required for every HYANNIS MA 02601 08/24/2015
page. Cityrrown 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
JEN T
o
i
I��►rl� A2- 254
Sal � AA- 245
b5.
604vV
3 s:t oNT
2 G5 2A
no A U.0 35
w
t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is required for every HYANNIS MA 02601 08/24/2015
page. Cityfrown 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: 104
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database -explain:
You must describe how you established the high ground water elevation:
HAND AUGER
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 63-65 SMITH STREET
Property Address
BOVE RICHARD AND LAWTON CINDY
Owner Owner's Name
information is required for every HYANNIS MA 02601 08/24/2015
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
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
i•I f y'y TOWN OF BARNSTABLE
4
LOCATION �✓� �'�I y' �S�' SEWAGE #
VILLAGE � �`?yIJS ASSESSOR'S MAP & LOT Z� l�Z— /'
INSTALLER'S NAME&PHONE NO. A01^& �As�- 7 71_�3,5
SEPTIC TANK CAPACITY ,-�d0 5 T'
LEACHING FACILITY: (type) 7 4_/. (size)
NO. OF BEDROOMS
BUILDER OR OWNER eX11-e- �
PERMTTDATE: Z�2 _/'9 COMPLIANCE DATE: L
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 Y
within 300 feet of leaching facility) Feet
Furnished by
N "a �' � � �
�_ .�
o m
� � - ,i,
Q CJ �
N - � :.
f /..
i
7
No. Fee= `
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
. PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZIppYication for ;Di9;po9;a1 *pgtem Construction Permit
Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) �omplete System ❑Individual Components
Location Address or Lot No. 3 Owner's Name,Address and Tel.No.- s Assessor's Map/Parcel
�Tr��/
„ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(.-ee
Other Type of Building wGe 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 ' tsae a �//J Type of S.A.S. J/2
Description of Soil 7
Nature of Repairs or Alterations(Answer when applicable) 7 0 Y/7
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 th' B and Heal
Signed Date
Application Approved by Date en7
Application Disapproved for the following reasons
Permit No. Date Issued ��
No. 94e— X" Fee ,d f
THE COMMONWEALTH MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
2pplication for Oie;pogal *pgtem Construction Permit
Application for a Permit to Construct( )Repair(V)Upgrade( )Abandon( ) .Complete System 11 Individual Components
1
Location Address or Lot No. Owner's Name,Address and Tel.No. i
!� 4
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
� 9 ,
- 7 / ,?
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(,1�0
Other Type of Building G No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �/� gallons per day. Calculated daily flower gallons.
Plan Date Number;of sheets I Revision Date
Title ?
Size of Septic Tank 1 f t5'O®Gy�,�� jf t Type of S,.A.S. A K
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
1 r ,
Date last inspected: x
Agreement:
The undersigned agrees to ensure th construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title of the Environmental Code and not to_.place the system iii operation until a CertifP
cate of Compliance has been issued y this Board i Health.
J, Signed _ Date
Application Approved by Date47
Application Disapproved for the following reasons r
c� c
Permit No. "" Date Issued ZJ '
——————————————————————————— ———-Y
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
y (Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (L- Upgraded( )
Abandoned( )by O
at — J 5 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit Nod V- °2., dated —2,47" �
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date \ 1 _ �(�� Inspector
----j-----------------------------------
No. t.'iC / �. � g=aTi�
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
'=i0po,5a1 *pgtem on5truction Permit
Permission is hereby granted to Construct( ),Repair( Upgrade( )Abandon( )
System located at�3� 3— Sal/7 5, �
lIZ42W T'c"
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 thi e®rmit.
Date: � -'" Approved �
r
L
to/9/97
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, � ", hereby certify that the application for disposal works
constructionp g Y permit signed b me dated Zl2y��� , concerning the
property located at d —����/ � /yO�IyJ�S meets all of the
following criteria:
There are no wetlands located within Ioo feet of the proposed leaching facility
ere are no private wells within 1-`0 feet of the proposed septic system
ere is no increase in flow and/or change in use proposed
ere are no variances requested or needed.
If the proposed leaching facility wiil be located within :50 feet of anv wetlands. the bottom of:he
proposed leaching faciiity will =be located less than fourteen %1-tl ,eei above the maximum adiusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) rGJ`f
B)Observed Groundwater Table Elevation(according to Health Division weil map) /- V
DATE:
SIGNED:
LICENSED
SEP
TIC SY
STEM
INSTALL
ER IN THE TO
WN
WN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
a
this plan should be submitted].
�r
• i �`Ya
IF Idth Folder:Cat .'.
VJI
.j o
h'
x*�
-r14 S I
D -
rirC C� �;ds
TOWN OF BARNSTABLE
SEWAGE #
LOCATION 3`�S ASSESSOR'S MAP &LOT
VILLAGE �0/��j �C4i�r57.
��
1NSTALLLER'S NAME&.PHONE N0.
SEPTIC TANK CAPACITY (size)
LEACHING FACILITY: (type)— -
NO...AF BEDROOMS
BUILDER OR OWNER l�
PERMIT
COMPLIANCE DATE:
Separation Distance Between the:
Feet '
azi>iium Adjusted Groundwater Table and Bottom of Leaching Facility
M an wells exist Feet
privsfe Water Supply Well and Leaching Facility (� Y
on site.or within 200 feet of leaching facility)
etlands exist Feet
Edge of Wetland and Leaching Facility
within 300 feet of leaching facility)
Furnished by
------------
F
I
� J
Z Z a
46::.J:2
, 9 -fr-d
X J �1
.�
TROY WILLIAMS a_'�--1_ 9 V
SEPTIC INSPECTIONS
Certified by MA Department of Environmental Protection 508) W5_1300
19 Hummel Drive
South Dennis, MA 02660 ��
1 J
-\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAI FB
N rq t
DEPARTMENT OF ENVIRONMENTAL PROTE41 VO- N tiq�FR 619
ONE WINTER STREET. BOSTON, MA 02108 617.292.5500UV C.,
WILLIAM F.WELD � UDY C
Govcmor �TR� OXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioncr
PART A
J( CERTIFICATION
Property Address 63 S S� f Sf Nyµ� s p f
y �yf1 Address of Owner: /V(�,�i u (�, i j�a.s�, S
Date of Inspection: (If different)
Name of Inspector: Troy Williams ` 6 0-"k 6 S 7
1 am a DEP approved system inspector pursuant to Section 15.340 of Title S (310 CMR 15.000) S i t, Al4
Company Name: _Troy Williams Septic Inspections
MailingAddress: _19 HLmmPI DriyP - Smith DpnniS , MA . 02660 Qv2 6 SS
Telephone Number: (0R8^38 5-13 0 0
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of 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: Date: a A
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 submit
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
Check A, B, C, or D:
A) SYSTEM PASSES: IV
I 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.
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES: N/�
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. /
Indicate yes, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If'not determined',explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or eAltration,or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(—i—d 04/25/97) P.y• 1 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 63&65 Smith Street,Hyannisport,MA
Owner: Myrna Williams
Date of Inspection:February 19, 1998
Bl SYSTEM CONDITIONALLY PASSES (continued) Al
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four 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
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 the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply. .
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than too feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revlud 04/25/97) o.n. ..♦ ,e+
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 63 &65 Smith Street,Hyannisport,MA
Owner:
Date of Inspection: MyMa Williams
February 19, 1998
DJ SYSTEM FAILS:
You m st indicate ei;,,er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No /
Backup of sewage into facility or system component due to an 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 1/2 day flow.
.j 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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 front a private water supply well with no
acceptable 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.
El LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
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 11 of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) _ry Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
63&65 Smith Street,Hyanttisport,MA
Property Address: Myma Williams
Owner:
Date of Inspection: February 19, 1998
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes, No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
/ as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
All system components,.excluding the Soil Absorption System, have been located on the site.
The 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:
1/ The facility owner(and occupants, if different from owner) were provided with information on the proper maintenance of
/ Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
_1L _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)]
(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 63&65 Smith Street,Hyannisport,MA
Owner: Myrna Williams
Date of Inspection: February 19, 1998
RESIDENTIAL: FLOW CONDITIONS
Design flow: LA/0 tz.p.d. room for S.A.S.
Number of bedrooms: p e, .5 Id 2
Number of current residents: /
Garbage grinder (yes or no): n/o
Laundry connected to system (yes or no): /V o
Seasonal use (yes or no): /1/D
Water meter readings, if available (last two (2)year usage (gpd):
Sump Pump (yes or no): j,L/v
Last date of occupancy: 6 c,i v/o, e �/ (oil , S ;c./
COMMERCIAUINDUSTRIAL• All',
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or-no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)
Water meter readings, if.available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and
source of information: /
/7 �O•t r i
System pumped as part of)nspi noct noct : (yes or no)-A-10
I(yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool w-, 4,L d d
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: ( 5 e-r o�—,
Sewage odors detected when arriving at the site: (yes or no) N d
(revised 04/25/97) o Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 63 &65 Smith Street,Hyannisport,MA
Owner: Myrna Williams
Date of Inspection: Febmary 19, 1998
BUILDING SEWER: A1/1
(Locate on site plan)
Depth below grade:
Material of construction: _cast iron _40 PVC_other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: !v b1
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _Fiberglass _Polyethylene —other(explain)
If tank is metal, list age _ Is age confirmed by Certificate of Compliance _(Yes/No)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How dimensions were determined:
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.)
GREASE TRAP: Al
(locate on site plan)
Depth below grade:
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:
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.)
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 63 &65 Smith Street,Hyannisport,MA
Owner: Myrna Williams
Date of Inspection:February 19, 1998
TIGHT OR HOLDING TANK:1119 (Tank must be pumped prior to, or 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/day
Alarm level: Alarm in working order_Yes;_ No
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX•
-- ?locate on sstc•pian)``
Depth of liquid level above outlet invert: GJ
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) _(jok
oC , ti ✓� Cd
C v K C J G v�7„�i .c J t h hJ '� /o L. ✓J -I-- J J�.cJ
PUMP CHAMBER: A11
(locate on site plan)
Pumps in working order:,(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/2S/97) ., Page 7 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: 63&65 Smith Street,Hyannisport,MA
Date of Inspection Myrna Williams
February 19, 1998
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: Okl c �j�� /� �-c t` /p >< w ; N( S74ah c ,
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:_DLk o✓ o w c,cc, S
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of pond�ing, condition of vegetation, etc.) 11
c_ G L✓ .ti s ✓G1 Lh
tnl hJ a (ram.✓ ( . / .lr� /
61
JQ
7<1�.. n q rd v n w—4-cr {.v
CESSPOOLS: ✓ dv<I /�.✓ CcssPv.� ( w�-s vh� tis4s� .cf G.4- S 7i^ c , /91So
(locate on site plan) /�✓h��u
Number and configuration:Okk�- r► h c tf c.o�a I
Depth-top of liquid to inlet invert: ". ~
Depth of solids layer:
Depth of scum layer: A/o/V C
Dimensions of cesspool: S
Materials of construction: C ,e-s c,
Indication of groundwater:_ P:7 $
inflow(cesspool must be pumped as part of inspection) 6 ro
//
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)' y
u ✓ l 6 f�D � ��� -s J cam? 7'L
tome- ✓� t.. "w, t O "C /h 0
r, ,p L h<..,i ✓ ��� �1, -� T' /Va 7`L�S r�J <-•-, +- can o
K, ,- w� -
PRIVY:A4 '9 y ro✓F._.2 ✓ j
(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.)
(revised 04/7S/97) - Page ! of to
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner: 63 &65 Smith Street,Hyannisport,MA
Date of Inspection: Myrna Williams
February 19, 1998
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
21
0
C9
4
M�.h
C�SS�o e I
(revised 04/25/97) Page 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 63 &65 Smith Street,Hyannisport,MA
Owner:
Date of Inspection:Myrna Williams
February 19, 1998
Depth to Groundwater/4 Feet 7. 3 adj=cd high groundwater lcvel
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
V/Observation of Site (Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
µr~� a a�yt✓t � - y���. J ; r J c.,
A�J� S � rti-c cn +- �,� ��� p �. C,rio.✓i-,of w 4-+c✓ lti c/� �/. /�� f'"-f-o � o 7' _
lL h f (ti/ 4 s I ./O �� S i 5 / u cam.! r✓ �'! C,rc1✓�.oC
G ro,(. ..� 6.1a �cv I��G I . Cjr�✓..v(wuc �U�o f S �ow
o Zh k. , n, y a �+ �✓ s f�� ,c
p
I., hoc ✓ / rc�,�✓ /
, !.
MC c' ri 1 .r; O 7" o T—
(revised 04/25/97) Page 10 of 10
Permit Number: Date:
Completed by:--—r—
HIGH GROUNDWATER LEVEL COMPUTATION
Site Location: h 3 ¢— G s 5,v, S-f. a Lot No.
Owner: ( , Address:
Contractor: Address:
Notes:
STEP 1 Measure depth to water table //9 �98 /G Q
tonearest 1/10 ft. .............................................................................. .Date
month/day/year
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
OAppropriate index well....................................................
OB Water-level range zone ..................................................... v
STEP 3 Using monthly report "Current
Water Resources Conditions"
determine current depth to
water level for index well ...........................
month/year
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A), current depth
to water level for index well (STEP 3),
and water-level zone (STEP 26)
determine water-level adjustment ..........................................................................................
STEP 5 Estimate depth to high water
by subtracting the water-
level adjustment (STEP 4)
from measured depth to water
level at site (STEP 1) ........................................ • 3
LO'=,,CATION 40SEWAGE PERMIT NO.
31 ?
V I L L A G J 'iv:
PARCEL NO.:
IN S T A LLEUS NAME A 0 D R'
S t
' ^ 1.
R U I L D E OR OWNER
DATE PERMIT ISSUED QrA j� � (��
i
DAT E COMPLIANCE ISSUED � ! 76
® V 7
"
r
a �
.3
a.
V c.
ASSESSORS MAP NO:
No. c :3�q PARCEL NO.. ----- -� �' Fizs.....
THE COMMONWEALTH OF MASSACHUSETTS
-BOARD OF HEALTH
....... OF........ ....................................
.....................
Appliration for Disvaaal Works Tonotrurtiun 1hrutit
Application is hereby made for a Permit to onstruct ( ) or Repair ( an Individual Sewage Disposal
System at: � `'
`
........._.. ....... ..................... ............•-•-••-•••--•..... ..-
. ` ..........................................
Loc n-Address or Lot No.
y^ ........ Q.�n..a...
... .. ......... ... ..�........_.._......._... ........_..................._.........._......._.......__•__........_.._.._..._._....•._..........
Owner e� Address
f.. = ILLY=.- -`-` ..�...........�Z:k .:�.........�_. ..
1.4 Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers — Cafeteria
a Other fixtures _________________________________ _
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 ..Septic Tank—Liquid capacity Length................ Width...._..._._.___. Diameter__._.________._. Depth................
Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --•-------------------------------------------------------•---••----•-•......-•••••......-----•--••.........................................................
0 Description of Soil......................•-----•------------•-•-•----------..--•--.....-----...----------------------------------------•------------............------......----•--•----...
U ------------------------------------
•-••-----------
--------------------
•------------
-.......
-............
------------------------------------------------------------
..........--------------•--•--------
W -----•--------------------------------------------------------------------------------------------------------- � f ._. r 1...........
---------------
U Natyre eof e airs 1 erations—Answer when applicable......_.��'`?.. ._I�. .1.............t_ 0._._.g .��_ _.:................
------------ �----......` ------------•--------------------------------------------•-----------------------------------------------------------------•-----•------------------•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITIE 5 of the State Sanitary Code The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has e 4niss ed by the boar of h lth.
Signed ... �� -o=... d_.................... �-
Application Approved By-------- J =�� .. ``:......--••--••-•-•---••..---•-- ...............-L/_
ate
Application Disapproved for the following reasons:.............................................................................................................._
-•••-----•-----------•--...•-••--••••-------•----------------•••••-------•...................---•---•-••---------•..........-----...------•-----...-------------------------------------------•••-•-•---
Date
PermitNo.. --- - ..._. Issued.......................................................
Date
FiczNo .... ..... . - .:
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF.......S,.. .........r...`.�:�. .....................................
Appliratiun for Disposal Works Tonstrnrtion Frrutit
Application is hereby made for a Permit to onstruct ( ) or Repair (�~Individual Sewage Disposal
Systemat: ---- ........ .. ....... ......... ..... -•..........................................
• -Loc n-Address .-.•. -•--or Lot No.
Owner ---• Address
a � ......... ......... ..•...... ................................... ......._. ±.:• -° - 'r'", s t #3 :. ..:...
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms................ ...._..._.._.......Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons........................---- Showers ( ) — Cafeteria ( )
C4 Other fixtures -----------------------•......---•-•••--......_
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area.................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
pr .............•••••--•--•-•--••-••-•...................-••-•--•-•-•--•••.•.... ..•--....-•----................-••--••-•-••••-•--••...............---•-•••.
Descriptionof Soil.........................................................•..............................................................................................................
•-•••-•---•-••-• -----•-----• •--•-•--•-•-•-•••----•----•••-••-•••••-•••••...............•--•-•-----•-•-•--•-
U Nat of Repairsllerations—Answer when applicable:.... u*.:......
..� . ----•--------------------------•................... -•.._... ........ •...•... •••_---- •........ ........ --•__.-•-........_...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T U 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has e n issued by the board of h lth-
Signed.L....A.......... -3. .................... Y........
y a
Application Approved By------- -��' _ .,t � ==......--••-•--------•-------------- ..................
/.
ate
Application Disapproved for the following reasons:...........................................................................................................
.........................•-----•-------•----.....--•-••-•-........-•---........--------........------.........----............---....------•-----...................---....-•••••.........••--•-••---•--
ate
PermitNo...... .... .. .�: _...__ Issued......................................................D _
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Tntif irate of Toutplittnrr
THIS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (�W
.� .,
by. .f.�. ...................................•---...................:.......................•.........._.........----.........-_............
1 Installer
My
at. '..�' ... .. £„t� -:... ....................-_......=�. i:-------------------------------------------------------------------
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code aq described in the
application for Disposal Works Construction Permit No.:! r :=_ 2��l.._...... dated.........44,. ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTJOV SATISFACTORY.
7 - •...
DATE................................... ... __....------
Inspector---•-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Na ; a `..:"�..............OF.....Y': f ✓ ....._..... F>a>�. ....
�io�ros Works G nstrtution �Cerntit
Permission is hereby'granted......... f
to Construct ( ) or Repair (fin I dividual Sewage Disposal System
at No..--.... ' c: ........: :::?�.... '........`--`��.......... �. -•---........
treet _
as shown on the application for Disposal Works Construction Permit Na` ..::_ �Dated.......... .1 .�'_�::.--.----:-
.. t� Board of Health
............. •• ti-'.........................
FORM 1255 A. M. SULKIN, INC., BOSTON �:,