HomeMy WebLinkAbout0070 STRAIGHTWAY - Health -�70 STRAIGHT WAY, HYANNISPORT
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LOCA`IION 1® a m- V _ SEWAGE #
Vrt..LAGE ASSESSOR'S MA.IP & LOT
rNSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY PP
LF.ACIENG FACILITY: (type) ��UW lei fi3 ®`�_ (size) x �
NO. OF BEDROOMS
BUILDER OR OWNER
... T DATE: S k%Z I Ct r, COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Feet
Private Water Supply Well and Leaching Facility (If any wells exist r
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) iJ 1 Feet
Furnished by
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LOCATION SEWAGE #
VILLAGE I. l S '. �' SSESSOR'S MAP &LOT !��16�`1�l
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO. OF BEDROOMS
BUILDER OR OWNER Q
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Town eof Barnstable
Inspectional Services
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'"'N`"RLIL ' Public Health Division
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o� 200 Main Street, Hyannis MA 02601
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
SECOND NOTICE
CERTIFIED MAIL#7015 1520 0000 1967 7559
August 15, 2019
VASCONCELLOS, CARLOS S AND SCARPA,
70 STRAIGHTWAY
HYANNIS, MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 70 Straightway Road,Hyannis, MA was inspected on
05/04/2017 by James D. Sears, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of.1995 TITLE V (310 CMR 15.00) due to the following:
f C Leaching pit or cesspool with high liquid level,<12" below inlet(pert Town
Code 360—9.1).
You are ordered to repair or replace the septic system within one (1)year from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Thoma�s'cean, R.S., CHO
Agent of the Board of Health
' Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\70 Straightway Road Hyannis
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Q ❑Adult Signature Required $
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� Vasconcellos, Carlos S and-Scarp
Ln 70 Straightway
o Hyannis, MA 02601
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Certified Mail service provides the following benefits:
■A receipt(this portion of the Certified Mail labeq. for an electronic return receipt,see a retail
■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate
■Electronic verification of delivery or attempted return receipt for no additional fee,present this
delivery. USPS®-postmarked Certified Mail receipt to the
■A record of delivery(including the recipients reel associate.
signature)that is retained by the Pcstal Service"' Restricted delivery service,which provides
for a specified period. delivery to the addressee specified by name,or
to the addressee's authorized agent.
Important Reminders.- Adult signature service,which requires the
■You may purchase Certified Mail service with signee to be at least 21 years of age(not
First-Class Mail®,First-Class Package Service®, available at retail.
or Priority Mail®service. Adult signature restricted delivery service,which
■Certified Mail service is notavailabbe for requires the signee to be at least 21 years of age
international mail. and provides delivery to the addressee specified
■Insurance coverage is notavallable for purchase by name,or to the addressee's authorized agent
with Certified Mail service.However;the purchase (not available at retatq.
of Certified Mail service does not cf ange the ■To ensure that your Certified Mail receipt is
insurance coverage automatically included with accepted as legal proof of mailing,it should bear a
certain Priority Mail items. USPS postmark If you would like a postmark on
■For an additional fee,and with a proper this Certified Mail receipt,please present your
endorsement on the mailpiece,you may request Certified Mail item at a Post Office-for
the following services: postmarking.If you don't need a postmark on this
-Return receipt service,which provides a record Certified Mail receipt,detach the barcoded portion
of delivery(including the recipient's signature). of this label,affix it to the mailpiece,apply
You can request a hardcopy return receipt or an appropriate postage,and deposit the mailpiece.
electronic version.For a hardcopy return receipt,
complete PS Form 3811,Domestic Return
Receipt;attach PS Form 3811 to your mailpiece; IMPOIRAHi:Save this receipt for your records.
IS-
3800,April 2ols(Reverse)F SN 7530-02-000•9047
SENDER: COMPLETE THIS SECTION • • DELIVERY
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■ Print your-nam' and address on the"reverse a. y �A9.`ent.
so that we can return the card to you. X `' ` ddressee
■ Attach this card to the back of the mailpiece, B. Receffiv by(,?dntteed Nie'el ), U.L Date of°belkery
or on the front if space permits. ��P 0S v =� Z) %, {
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Vasconcellos, Carlos S and Scarpa �, s2
70 Straightway
Hyannis, MA 02601 -- 0
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First-Gass Mail
Postage&Fees Paid
USPS
Permit No.G-10
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United States •Sender:Please print your name,address,and ZIP+4®in this box*
Postal Service' - - - - - - - -
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f Health Division
200 Main Street
Hyannis, MA 02601
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Certified Mail service provides the following benefits:
■A receipt(this portion of the Certthec Mail labeq. for an electronic return receipt,see a retail
■A unique identifier for your mailpiece. associate for assistance.To receive a duplicate
■Electronic verification of delivery or attempted return receipt for no additional fee,present this
delivery. USPS®-postmarked Certified Mail receipt to the
■A record of delivery(including the rceipient's retail associate.
signature)that is retained by the Postal Service' Restricted delivery service,which provides
for a specified period. delivery to the addressee specified by name,or
to the addressee's authorized agent
Important Reminders. Adult signature service,which requires the
■You may purchase Certified Mail service with signee to be at least 21 years of age(not
First-Class Mail®,First-Class Package Service®, available at retail).
or Priority Mail®service. Adult signature restricted delivery service,which
■Certified Mail service is notavailabls for requires the signee to be at least 21 years of age
International mail. and provides delivery to the addressee specified
■Insurance coverage is not available for purchase by name,or to the addressee's authorized agent
with Certified Mail service.However,the purchase (not available at retail).
of Certified Mail service does not change the ■To ensure that your Certified Mail receipt is
insurance coverage automatically included with accepted as legal proof of mailing,it should bear a
certain Priority Mail items. USPS postmark If you would like a postmark on
■For an additional fee,and with a proper this Certified Mail receipt,please present,your
endorsement on the mailpiece,you may request Certified Mail item at a Post Office'for
the following services: postmarking.If you don't need a postmark on this
-Return receipt service,which provides a record Certified Matt receipt,detach the barcoded portion
of delivery(including the recipiert's signature). of this label affix R to the mailpiece,apply
You can request a hardcopy return receipt or an approprlate�ostage,and deposit the mailpiece.
electronic version.For a hardcepy return receipt,
complete PS Form 3811,Domestic Return
Receipt attach PS Form 3811 to your mailpiece; IMP096tt1:Save this receipt for your records.
Ps Form 3800,April 2015(Reverse)PSN 7530-02-000.9047
e Complete items 1,2,and 3. A. Signature
■ Print your name and address on the reverse X ❑Agent
so that we can return the card to you., ❑Addressee:
Id Attach this card to the back of the mailpiece,', B.-Received by(Printed Name) C. Date of Delivery
or on the front if space permits.
1. Article Addressed to: D. Is delivery address different from item 1? ❑Yes
If YES,enter delivery address below: ❑No
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Town of Barnstable y Barnstable
Regulatory Services Department AEAmmicaCky
BARNSfABLE,
Ate. Public Health Division
Arf°µAAA 200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7015 1730 0001 4990 6531
June 8, 2017
FEDERAL HOME LOAN MORTGAGE CORP
8200 JONES BRANCH DRIVE
MCLEAN, VA 22102-3110
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 70 Straightway Road, Hyannis,MA was inspected on
05/04/2017 by James D. Sears, certified Title V Septic Inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Fails" under the guidelines
of 1995 TITLE V (310 CMR 15.00) due to the following:
• Leaching pit or cesspool with high liquid level, <12" below inlet(per Town
Code 360-9.1).
You are ordered to repair or replace the septic system within two (2)years from the date
you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
g
ER OF THE B ARD OF HEALTH
cKean, R.S., CHO
Agent of the Board of Health Y
Q:\SEPTIC\Title V Inspection Report Letters Mailing\Failed or Needs Further Evaluation Letters\70 Straightway Road Hyannis.doc
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~ "* Town of Barnstable
019. ,�� Regulatory Services Department
Public Health Division
200 Main Street,Hyannis MA-02601
Office: 508-8624644 J
Richard Scali,Director
FAX: 508-790-6304 Thomas A McKean,CHO
Feb 6, 2007
Rev. 5111116
DEADLINES TOREPAIR FAILED SYSTEMS .
(Town Code §360-44 and Title V: 310 CMR 15,000) _
An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑Discharge or ponding of effluent to the surface of the ground .
❑Pumping more than 4 times during the last year not due to clogged or obstructed
pipe.
❑Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (I)YEAR DEADLINE CRITERIA.
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if the water analysis
indicates the well is free from pollution).
2 YEAR DEADLINE CRITERIA
❑Any"conditionally passed systems" (broken cover,relocation of a pipe,relocation
of a driveway due to H-10 components, etc)
chmg pit or cesspool with high liquid level, <12"below inlet(per Town Code
360-9.1)
❑Leaching facility with standing liquid level at or above the invert pipe (per Town
Code §360-20 h) '
OTHER
Repair deadline:
QASEPTICIDEADLINES TO REPAIR FAILED SYSTEMS.doc
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Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,
M 70 Straightway Road
Property Address
Freddie Mac 's
Owner Owner's Name �*1
information is
required for every Hyannis MA 02601 5-4-17 X
page. City/Town State Zip Code Date of Inspection
61,
Inspection results must be submitted on this form. Inspection forms may not be altered in y
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms �i - /a23&3
on the computer, \``���� �,tH OF
SS
use only the tab 1. Inspector: �02� ' 9°tip
key to move your =�: JAMES
cursor-do not James D.Sears =
use the return - e= cr--e-1=A p5 n
key. Name of Inspector
Capewide Enterprises
Company Name { ! N
153 Commercial Street ,F�s/INS?
Company Address
few
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
❑ Passes ❑ Conditionally Passes ® Fails
❑ Needs Further Evaluation by the Local Approving Authority
5-6-17
pector'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 should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
}
s , ;
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is required for every Hyannis MA 02601 5-4-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ 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:
Failed system - Leaching. The system is a 1000 Gal. Tank D Box and two chambers.
13) 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):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
f
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is required for every Hyannis MA 02601 5-4-17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is required for every Hyannis MA 02601 5-4-17
-
page. Cityrrown 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:
**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:
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 is less than 6" below invert or available volume is less
® El than Y2 day flow/,£ACIIIAJ�
t5ins.doc-rev.6/16 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
M 70 Straightway.Road
Property Address
Freddie Mac
Owner Owner's Name
information is required for every Hyannis MA 02601 5-4-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
® ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ 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.doo-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is required for every Hyannis MA 02601 5-4-17
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): NA Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
L
Commonwealth of Massachusetts
4 v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is required for every Hyannis MA 02601 5-4-17
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank D Box and two chamber's.
Number of current residents: 2
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)): 2015-27,000Gals
2016-32,000GaI s
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trapresent? Yes No
P ❑ ❑
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 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 70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is required for every Hyannis MA 02601 5-4-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6/16 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
;M 70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is required for every Hyannis MA 02601 5-4-17
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:
NA
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"
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.
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: 1000 Gal. Precast H-10
Sludge depth:
2" �
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is required for every Hyannis MA 02601 5-4-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
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 8" below grade. In and outlet baffle's. No sign of leakage.
Tank should be pumped.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6/16 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
,M 70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is required for every Hyannis MA 02601 54-17
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.):
t
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is
required for every Hyannis MA 02601 5-4-17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-10" Below grade w/one line out.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is required for every Hyannis MA 02601 5-4-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ 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.):
Leaching is two flow's. Leaching at 32" below grade. Leaching is full up to inlet tube. Not leaching.
Need to replace.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is Hyannis MA 02601 5-4-17
required for every y
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is required for every Hyannis MA 02601 5-4-17
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
cpg
UPPER
A- 1= ck
r
Jr
l3 `a� 3' T
�17
13
jq G �,
/3- y: 7°
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is Hyannis MA 02601 5-4-17
required for every Y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑. Shallow wells
Estimated depth to So ground water: 18
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:
G.W. from Barn,G.W. map. 18' to G.W.. Bottom of chamber's at 4'-2" below grade. Bottom of
chamber's at 13'-10" above G.W. Depth.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
70 Straightway Road
Property Address
Freddie Mac
Owner Owner's Name
information is required for every Hyannis MA 02601 5-4-17
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
, f
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
70 S_ traic�htway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601
10-5-12
every page. Cltylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way: Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms the � qo
computer,
r,use 1, Inspector:
only the tab key
to move your Darrell Stone
cursor-do not Name of Inspector
use the return
key. Cape Cod Septic Inspection
Company Name
VQ PO Box 1466
Company Address
Harwich MA
2645
City/Town State 0 p Code
508-240-2500 S14995
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:
® Passe ❑ C d' onally Passes ❑ Fails
❑ N rt r Evaluatio by the l- pprov uthority
10-5-12
In ecto Signature Date
The system inspector sha submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
'"""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address dress how the system will perform in the future under
the same or different conditions of use.
dI
t5ins•11/10 �
Title 5 officiVV .norm:Subsurface Sewage Disposal System-Page 1 of 17
� a
!
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
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):
t5ins-11110
Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Sub
surface Sewage Disposal System Form-P Y Not for VoluntaryAssessments essments
70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every page. Cltyfrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cunt.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N
❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
I. 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
[Sins•11110
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of l;
s
Commonwealth of Massachusetts r�
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every 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:
**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 m provided that no other f PP , P e allure criteria are trig
gered. A co
py opy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than %day flow
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,. 70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Ell ® 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.
gg ed.A copy of the analysts
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 If of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every page. City/Town State Zip Code Date of Inspection
C. Checklist
r
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 b P 9 p the owner, occupant, or Board Y of Health
P ,
❑ ® 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): Na Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
` 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,••�''v 70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
2 Bedroom residential dwelling*
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use?
. El Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump?
❑ Yes ® No
Last date of occupancy: 10-2012
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s ' 70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Unknown
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary.Assessments
,••�''a 70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every 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:
Unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 10"+/-
feet
Material of construction:
❑ cast iron Z 40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Apparent good condition
Septic Tank(locate on site plan):
Depth below grade: 411feet
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: 1000 gallon
Sludge depth:
12"
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
r ,
Commonwealth of Massachusetts
MENEM
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s. 70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt.)
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
10"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
7"
How were dimensions determined? 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.):
Normal liquid level No sign of leakage Concrete outlet tee OK
Recommended maintenance pumping.
Recommended maintenance pumping every 2-3 years
Grease Trap(locate on site plan):
Depth below grade:
feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene
El other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins•11/10 Title 5 Official Ins pectian Form:Subsurface Sewage Disposal System•Page 10 or 17
Commonwealth of Massachusetts
Title 5 official Inspection. Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain):
Dimensions:
Capacity:
. gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 `
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box„etc.):
Grade to box 11" OK condition Normal liquid level No sign of leakage No scum
No sign of failure
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
ti
Commonwealth of Massachusetts
Title 5 ® iciel Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number.
® leaching chambers number. 2
❑ 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.):
2 (4x8x1')chambers with stone
Grade to chamber 34" Bottom 53" Ponding 1"
No sign of hydraulic failure
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every 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.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•11110 Title 5 Official Insp
ection 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
r` 70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every page. Cltyfrown 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
e s within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
t
A B
1 Z�_ 6
2
3 10
a 4 67 270-0
5
6
t5ins•1 Ill 0 Title 5 Official inspection Form:Subsurface Sewage Disp
osal posal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: >4
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:
Previous inspection on file
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Test hole results from previous inspection
Bottom of SAS 54"
Bottom of Test hole 126" NWE
Separation >4'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
70 Straightway
Property Address
Freddie Mac
Owner Owner's Name
information is
required for Hyannis MA 02601 10-5-12
every page_ Cltyrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
TOWN OF BARNSTAB ,;
LOCATION a ,`/-97 ar
SEWAGE # C�D
VILLAGE �I/�I��tI,S ASSESSOR'S MAP & LOT
t
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY )n
-LEACHING FACILITY:(type) o"1 (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER Ise✓ %�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
r4 �`:
No... .......... FICIC /�
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN BARNSTABLE
_...............0 F....... - ------•---•
Application is hereby made for a Permit to ConstructS( X) or Repair ( ) an Individual Sewage Disposal
` System att
K.. 87 Straiht Wy offyis 87
................
........ .
---•-------------------------•-----------
Bui`� 'W'6Y ressBomes 1061 Route 6A,Brewster,MA 02631
......................--.......................................................................... ..........--..................................................................
wner Address
Installer �,'1 Address
UType of Building (,(,0 Size Lot....--8!.813----._..Sq. feet
Dwelling—No. of Bedrooms............... '_'...._..._...___.__.Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fix 5 es ..--•-•--•--•-•---------•----•-----•-----•---------•--'--------•-•--•-••------•-..._-•-------•------------------•--•------------------................
W Design Flow.............................................—gallons per person per day. Total daily flow------ gallons.
G: Septic nk—Liquid capacity__.100 allons Length.8.__...�.... Width.5_....i� Diameter------------- De th.5'.�11._..
W Flo U s f s '\To...__......2.... Width_...__12.'...... Total Len tli___...2.4.'_._.... Total leaching area ft.
x —- --- s 1; q.
Seepage Pit No..................... Diameter.............-...... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box (X ) Dosing tank ( )
'_' Percolation Test Results Performed by._-___-_-Doyle Engineering Date----- P7620
Test Pit No. 1.....<_2__minutespper inch Depth of Test Pit.......5-'....... Depth to ground
ound water----B_1 __l.0-w-3 (5 1 )
f3, Test Pit No. 2... .._.__....minutes er inch Depth of Test Pit-------- 6•_-. Depth to round water_E1__-_..1.0--_4 (8 6 )
a ----- ------------------------
O Description of Soil.....(-1 ) 0 - 24" Topsoil, 24" - 36_" Subs-Q.i._],.,-36" -.6_Q".__Fine.._.ta.........
� medium sand. ........
F _�_._to...med i.),m_._aa id-
U Nature of Repairs or Alterations—Answer when applicable._______________________________________________________________________________________________
----------------- ---------------------------------------------------------------------------------------------•----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal "ystem in accordance with
�'1 T f'1 x!.
the provisions of 1� t LE 5 of the State Sanitary Code he n' signed further agr {not to place the system in
operation until a Certificate of Compliance has been iss e a f lie th.
Signed--------- --------
. Da
Application Approved By._ . --- •. ® --•---/� --------
ate
Application Disapproved for the following reaso --------------------------------•----......--------------------------------------•- .............................
------------------------------••--•---•-...-----------•...-----------------------------••--•-------•--•-•'-•.........._...•-----------•-----•-----
Date
Permit No. ..... - ------- Issued f --------------------------
L
No. ------- Fss. ..........................
r/w/ �! !Q
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,OF HEALTH
TOWN BARNSTABLE
...................... .............-----OF..............
Appliration for DiiiVogal V`irks (9vimtrurtion Prruat
Application is hereby made for a Permit to Construct X) or Repair an Individual Sewage Disposal
System a,
............. .8.7...Str.a.il��... 87
.... ............
BUJI*ion4�yj�,,HoMee
W 1061 Route 6A,E°i ewLo, Nter".NA 02631
e
................................................................................................. .......................................i...... ..............................................
Owner Address
.................................................................................................. ..................................................................................................
Installer Address
Type of Building -Fujo Size Lot..._..8 ..1,813...
Whrree, ... ........... ---Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder,
aOther—Type of Building ............................ No. of persons............................ Showers —'Cafeteria
•�•-=--)
Other U fires
Design Flow__________________ 11 ns per person Ver day. Total daily flow..........330..........................gallons.
a 'o .........
9 Semi -Tank—Liquid capacity..Wfaillon' s Length.8 6 4"
............ Width--5........... Diameter------!n7..... De
F1 �ptj-1_5
6.1LALMness No...........1....... Width.__-__..... Total Length.....24.1....... Total leaching area--- "'.'..sq. ft
> Seepage Pit No----_--_----------Diameter.................... Depth below inlet._......._._.._..... Total leaching area..................sq. it.
z Other Distribution box (X ) Dosing tank
le Engineering90
Percolation Test Results Performed by.......................................................................... Date....JulA!4y--- ................ P7620
Test Pit No. I.... 2---minutes per inch .Depth of Test Pit........5.1....... Depth to ground water -8.1-------1-0 w,3
'
Test Pit No. 2 7-<.. ....minutes per inch Depth of Test Pit........8...6... Depth to ground water-91 _�..Jb 4� - .4 86" )
....................................................................................................................................................
0 Description of Soil.... ............. Topeoil,2411 — 36" Sk2
------------------------------------------
-b
mid'fum .........
..................................Q.)....0...........................................................................................................................................
24" Top and eubeoilt2--------------- ----------------------------------------------------------...................................... 4 ..to...MeAiu
�i 11--------- ---- Ji -sand
Nature of Repairs or Alterations—Answer when applicable_________________......_.............................................................. ..........
k.
.................................................................................................. ..................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal ystem in accordance with
the provisions of'T'LE 5 of the State Sanitary Code;;7ihe n' signed further agr riot to place the System in
operation until 'a Certificate of Compliance has been iss e e aid f he th.
Signed......... ..........
,A� ....................... ----- .. .. ............. ......
Application
. ...........
caon Approved ppliti A d B ....... .. V ate
ate
Application Disapproved for the following reaso ............................................. ...............................................................7-
...................................................................................................................................................... ...............................
-----------
Data
Permit No---- 3 L,70k 1-1/. --------- i Issued..... /)
------------------7........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................TOWN............1 . OF................BARNSTABLE
........... .....................................................................
T rtifiratr of Tompliaurr
h THYL,11 r T TIF hat t ndiivtual�e Djsposal System constructed or Repaired
by... J -------------------- ------ --------------------------------------------------------
t
at------ - ------- ---- _- ---------
----------- .314S......................................................
5
the provisions of TII
a has been installed in accordance with tl of e State Sanitary Cod as de- in the
application for Disposal Works Construction Permit No.__..._ dated_--...__ . ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A G2 VEETHAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE............................................................................... Inspector...............................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.........TOWN
........T0 WN.. BARNSTABLE
......... ...OF.....................................................................................
No.. ...10MA...
Tons urtinn Vrrmt)t�,
Permission s hereby granted..._.......... ...................................
to Construct �•--
epair (4an IndividualAyw..ge Dis st S�
atNo-1.0-T- 16�.H..Tw.... ......;1..... ee - ___ --_--------_--- ---------
P.-yS,-r
3,
as shown on the application for Disposal Works Construction Permit No.�V...�. _A ated..... ..........
_b( 7//
........................................ - -.4. ...........................................
DATE.................. ?0.................................. B rd of Health
FORM 1255 HOBBS & WARREN, -INC., PUBLISHERS
i •
•s•
SOIL
N`0, 1 �8
NOa 2 �L: �
�. 0
PLA w
7
• 3 .• Ai'
Al /d.3
SAND
TOP 0F_ . F.OUNDATION EL ' zdAA*A4
l 17
-r--r-� .
am
no
• IN It /7.90 12.
I ,
1 1.
0/ 8 W/ 0 SUMP scop�� o.dos w r
13
4 LIQUID LEVEL ' l
. . ... . . . . . ..
2 fa 4
. . .. . .. . .. .
d9G EFFECT/V� D�PT"N , ' f ti'A�'H� 5"Ale PEt1C TEJ'T KESU�•TS
° P E R C RATE :
OSECAST SEPTIC TANK WITH
W H I T N Is S E 0 By ar✓A b&ARR Y_...
CAST 1N PLACE I N L F T AND
OUTLET T 'S PER TITLE V.
¢" g, "� ¢' ALZ AROVAID BOARD OF HEALTII
/000 GAL L ON . 5v;rEAV/o 09
2 DATE :
SIZE : _
(8'�'LONG • vc q.. A11,0E x .S'7"DEEP, A/A L P N0. -,1*6 2 d '
`YATFR ENCOUNT'ffteP N......
PR W* A- GF SYSTEM
SYSTE�` �� t1 • :J �•� h���r► C ^e ��_�T /. .. - _ REGULATIONS ,AND
iiI U JI � '1 � � �, I flE 1 iiiL i _lII
STATE TITLE V FOR SUBSURFACE DISPOSAL OF SEWAGE . , SCALE : '1/4"m V 0 `+ .Scy o
/, Iti Lor 97 X
3¢
N . 864A F -
li ALL PIPES SHALL BE SCHEDULE , 40 P,V.C ,- SEWER PIPE '
2, ALL PIPES SHALL BE SLOPED 1 /4 � PER F 0 0 T EXCEPT FOR i ,or sc hRw wAy z/. ,IG\ o � �9e, Zb
o ,
THE FIRST Z EEET OUT OF THE 0 / 6 WHICH SMALL BE LEVEL
W BE0R00MS AT 11O GALOAY PEA BIq , GAL / 0AY �
G
330 /5 495" PAO
/�, /d
I SEPTIC TANK SITE X GAL , bo ,� 21-6
USE .,., ..` G AL, W l 014- GARBAGE '01SP0SAI `{, �� � : way �v�CE � h� � r AOV
P�
s
X , "e—zew D/FP//SOR•S !Q//Ty Igi1/ EF "CT/V� - `' Q SEPTIC T�IAIK /
LEAI, HING SYSTEM . USE '�z� e I
•¢ XT D/r S1IVE AGL APDU/VD. 3 , W x
�� 1 m o, W w y 4 spy\ o
/ �, �. I z�• A« Aye p o
EFFECTIVE AREA : - SIDE <r��►/ram--z4� C�fC� zs� t /7z �z/eAY 1� I ¢ Q 3 } , 4e / o o �
BOTTOM C/x�. > (�� r z08 G.4mY `<
/ o
4G0 6`,41/D.�?Y I v
T T I Ib 3 /G / //G'
U AL FLOW
•
'a FLOW • X Ib -_TOTAL REQ
I1ES[ RVE FLOW GAL � 0Ay,
_. 7Sr N
8
2S6
-
,y G,4RAG
R r: N C E P L A N S A R.P. P4/1A/ d& tr/ ^9 .Z/
6'C.iP D. PLAN 8k. 0 y 'Or. d¢
APPROVED 3Y
DE XEAIT
AI-41V sc,41-E
DATE
� MPERTY OW,Nt A SITE AND SEWAGE PLAN
,SH OF
Map I ��ktH OF gsf9 F 0 R L L i/ai`��"S
M
BEDROOM SINGLE' FAMILY OWELLI �uG
o Rt7 RT, o t►. �,
-� L 0 T :,#7 srRA1aw7 t1 4 Y
c.a COYLE Ill -•
v DAVIDSON No.33°J89 N
No, zasoo 0 A T E • JUL 9, ./990
$7 ��a��� AfCISTE���pQ'
1 - DD L ;,,: a; ASSOCIATES EAIMOUTK MASS .
AIE� SUR��y 1
i