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Commonwealth of Massachusetts o��9—+/�s / G✓
y Title 5 Official Inspection Form
' hl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Suomi Rd �^
Profierty Address .
Charles Ferguson '
Owner Owner's Name
information is H annis MA 02601 5 J.required for every y -6-20
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information
Shawn Mcelroy
Name of Inspector-
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
East Falmouth MA 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed
above;the information reported below is true, accurate and complete as of the time of my inspection; and
the inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that
the system:
1. ® Passes
2. ❑ Conditionally Passes
3.. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
5-6-20
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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
'e,' Commonwealth of!Massachusetts `
p Title 5 Official Inspection Form
Y�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r
41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name
information is required for every Hyannis MA 02601 5-6-'20
page. City/Town 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.
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
2) System Conditionally Passes:
❑ One or more system components as described in the "Co nditionalPass" 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. 11
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 El ❑ ND (Explain below):
L
t5insp.doc•rev.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection . Form
i i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
1s. ? 41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name
information is
required for every Hyannis MA 02601 5-6-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ' ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑Y ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.1/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
!'I 01 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
...... 41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name
information is required for every Hyannis MA 02601 5-6-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water -
❑ Cesspool or privy is within 50 feet of a bordering vegetated wet•and 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.
OThe system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑The system ha.s 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: T
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 ,
❑ ® IDischarge or ponding of effluent to the surface of the c round or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
! ibt Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name
information is Hyannis MA 02601 5-6-20
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
, . Title 5 Official Inspection Form
C.I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name
information is required for every Hyannis MA 02601 5-6-20
-
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of.any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
Should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for sign's 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?
® El Wasthe facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
�.� Title 5 Official Inspection Form,
r�i Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
r�r�l
_T, >' 41 Suomi Rd ;
Property Address
Charles Ferguson
Owner Owner's Name
information is Hyannis MA 02601 5-6-20
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Description:
a
Number of current residents: 2
Does residence have a garbage grinder? f ❑ 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 El 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:
1
Sump pump? ❑ Yes ® No
Last date of occupancy: 1 5-2020
Date
t5insp.doc•rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
(e�N Commonwealth of.Massachusetts t
I
Title 5 Offi'cialInspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
} a
41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name '
information is required for every Hyannis MA 02601 5-6-20
page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
".Type of Establishment:
Design flow (based ron 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 occupan3y/use: Date
Other(describe below):
3. Pumping Records:
Source of information: Owner---pumped 2018
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
a Title 5 Officials Inspection Form
p Subsurface Sewage Disposal System Form -Not for,Voluntary Assessments
41 Suomi Rd ,' r
Property Address „
Charles Ferguson
Owner Owner's Name
information is required for every Hyannis MA 02601 5-6-20
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.) ,
4. Type of System: Z
® Septic tank, distribution box, soil absorption system , 4r
❑ Single cesspool r
❑ Overflow cesspool .
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any).
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed(if known) and source of information:
2005
Were sewage odors detected when arriving at the site? . r ❑ Yes ® No
5. Building Sewer(locate on site plan): ,
Depth below grade: 18"feet
Material of construction: '
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
,5 Title 5 Offic-ial Inspection Form
� ► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name
information is required for every Hyannis t MA 02601 5-6-20
-
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) a
6. Septic Tank (locate on site plan): '
Depth below grade: -12"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age` ' years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1500 gal
Sludge depth:
6"
11
Distance from top of sludge to bottom of outlet tee or baffle 26 '
Scum thickness
1n
6"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
. 15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18
2 ,\ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name
information is required for every Hyannis MA 02601 5-6-20 .
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction: .
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I
t .
8. Tight or Holding Tank (tank must be pumped at time of i nspecti on)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r�l Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments
41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name
information is required for every Hyannis MA 02601 5-6-20
page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
8. Tight or Holding Tank (cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order:' ❑ Yes ❑ No
' - Date of last pumping: '
Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box (if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if bcx is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from field.
}
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
pit Title 5 Official Inspection Form
Ni Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
r
41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name
information is Hyannis MA 02601 5-6-20
required for every •. -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
' Pumps in working order: { E Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type
❑ leaching pits number:
® leaching chambers number: 4-110's
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18
Commonwealth of Massachusetts '
r Title 5 Official Inspection 'Form �
hl. Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments '
b �r>
F iJ_ 41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name
information is required for every Hyannis MA 02601 5-6-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach chambers in good condition and empty at inspection with no visible stain lines.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer -
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
0,1 Subsurface Sewage Disposal System Form -'Not for Voluntary Assessments
a �+a
41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name
information is required for every Hyannis MA 02601 5-6-20
page. City/Town State Zip Code Date of Inspection
D. System Information,(cont.)
13. Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids `
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
I
r
i
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
1
Commonwealth of Massachusetts _
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments =-
i? > 41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name
information is Hyannis MA 02601 5-6-20-
required for every H y '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
C., 119
� f
C) Py
3
f
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 '
Commonwealth of Massachusetts
Title 5 Official . lrspection form
'Q Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name
information is required for every Hyannis MA 02601 5-6-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam: ,•�; u ,
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells ,
Estimated depth to high groundwater: 121+
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If.checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
I
I
Commonwealth of Massachusetts s r
Title 5 Official Ins ection Form
w.,
? as i Subsurface Sewage Disposal.System Form Not for Voluntary Assessments
r
7 , %�' 41 Suomi Rd
Property Address
Charles Ferguson
Owner Owner's Name /
information is
required for every Hyannis MA 02601 5-6-20
page. City/Town State Zip Code Date of Inspection
E. Report Complleteness 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.- s
For 8: Tight/Holdling 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.7/2 61201 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
CONTRACT' Customer Name "!- )
Customer Signiture_.�
SKETCH- Contract Date Sales Representative SignAture....":
7 ATTACHMENT Customer Phone
........ Contract Price.......'
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NOTES:
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(I aIS
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TOWN OF BARNSTABLE
Health Division— 200 Main Street - Hyannis, MA 02601
FAX C� Date: �� D S
r
+ BAMSrABM
v Mass. $ Number of pages including cover sheet:
1639. ♦0
To From: SHARON CROCKER
ke V; Town of Barnstable
W
j , Health Division
s
p� Mail to: 200 Main Street
Phone: J—O 4 /�/ �� " �1600 Hyannis,MA 02601
Fax phone: Phone: 1-508-862-4642
CC: Fax phone: 1-508-790-6304
REMARKS: ❑ Urgent ❑ For your review ❑ Reply ASAP ❑ Please comment
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T 1 uw. I CD I SC-(���4'L�������q� 'FZI ,
EXISTING
# 1 GRADE ••r��;�'�;. d,
100.0— y # 2
99.1 — SANDY LOAM — 100.0
97.5 — — 99.1
LOAMY SAND �#?.
97.5
.1
PERC RATE < LOCUS MAP
2 MIN / IN.
DESIGN
MEDIUM
COARSE SAND SINGLE FAMILY DWELLING W/3 BEDROOM
AND GRAVEL NO GARBAGED15PO5AL S
DAILY FLOW= 110 X 3-330 G.P.D.
SEPTIC TANK(VOL.REO•D)
330 G.P.D. X 2 = 660 GALS
90.0 — 1,500 GAL.TANK-O.K.
NO WATER
90.0 LEACHING AREA(5.A.5.)
USE 4-3'X G'X 2' P.C.CONC.L.C. +4'STONE ON END
TESTED 07/1,5/05 EFFECTIVE DEPTH=2.0 3.5 ON SIDE
2X[G4+26)X0.74 _
- 124
IOX32XO.74
= 237
NOTES: TOTAL CAPACITY = 361GALS.
I. DISPOSAL SYSTEM TO BE CONSTRUCTED IN STRICT ACCORDANCE WITH
COMMONWEALTH OF MASSACHUSETTS ENVIRONMENTAL CODE-TITLE V.
2. ASSESSORS PARCEL NUMBER(APN):MAP 2G9-PC. 1 15
3, CONTRACTORS O CALL DIG-SAFE 72 HOURS PRIOR TO BEGINING CONSTRUCTION AND/OR EXCAVATION.
5. EXISTING PITS TO BE PUMPED AND FILLED WITH.`SAND,AND AggNppNED.
5. CONTRACTOR TO FIELD CHECK INVERT OF EXI.S;ING TANK
G. USE J 500 GALLON 5EPTIC•TANK WITH T'S AN?GAS BAFFLES PER MADtp TITLE V.
7. THIS PLAN DOES NOT, IN.ANY WAY, REPRE5ENF AN ACCURATE;'INSTRUIv1ENTTLE v. Y OF TH
TO BE USED FOR ANY CONSTRUCTION,OTHER THAN THE ELEMENTS
8. THIS PLAN 15 NOT A RECORDABLE PLAN. E PROPERTY,AND IS NOT
9. BENCHMARK 15 BASED ON AN A55UMED DATUM,AS SHOWN, UNLE555 OTHERW 5E SPECIFIED.
1EM AS SHOWN.
10.5UVREyOR: HOOD SURVEY GROUP, LLC: P.O. BOX 231:SANDWICH, MA 025G3
I I. USE 4 G'X 3'X 2'P.C. CONCRETE LEACH CHAMBERS W 4'OF 3/4"- 112"DOUBLE WASHED STONE ALL AROUND
WITH 2"OF PEA5TONE ON TOP.
12. PLACE 40 MIL BARRIER BETWEEN HOUSE FOUNDATION AND SEPTIC LEACH FIELD.
13.THI5 BARRIER WILL ALLOW FOR A REDUCTION FROM 20'- 17 FROM HOUSE FOUNDATION
TO EDGE OF LEACHING AREA.
14.THI5 REDUCTION REQUIRES A VARIANCE FROM THE HEALTH AGENT.
H OF*, NOVA OF N
HA ` St g o� 9c RICHARD ycN
o EARLS'^.\ o J. a
UINTERY,/R. c " HOOD y
O•AFNm 26575 Q " �No.35031 0
N BR� PQ SAC'/STER��``�
SEWAGE SYSTEM DESIGN
HEALTH AGENT APPROVAL FOR
DATE
LEGEND ERIC PAONE
ON
24 PROPOSED CONTOUR SUOMI DRIVE lfL��Nnri
10 EXISTING CONTOUR HOOD SURVEY GROUP,LLC. A.T.S .
LAND SURVEYOR
D S CONSULTING ENGINEERS
RIVEWAY IB ROUTE 6A"C SANDWICH,MA 02563 P.O.BOX 99
"B" FIRM ZONE E.SANDWICH,MA 02537
DATE: 21JUL05
SCALE: I^= 20
f moo 3'-35/ l���n ! �
LCP 11328
i
C�
14I1.5' M'. P/\T 10
/D13!1:II C(:.:F),
10.a
S.T. S.d a
GGI
CI
G
I
0.0'F17.0' No 41
1 5TY.
10.0 40 mil /WD.FRM.' D.B 1
11 .XII
I BARRIER 1 5T jL. = 103:36
EDGE OF PAVIJ/11I,!''
h
'LT
FIR5T FLOOR 51TE PLAN
EL. 103.3G
TOP OF WALL
FIN.GR.EL.-LQQ.QO EX15TING GR.EL.84.0
296 SLOPE ❑.. 100.0
W/IN G'OF GR
\ \ a i\ \ \\i\
FIELD 9'MIN.COVER // F,_6.Ma.
CHECK /\� 2'PEA5TONE
H2 0 TE5T ACCI[55 POP,TS
\EL 98.0 OR LEVEL
1,000 GAL EL.97. D-BOX 2'LEVI:I.
ro
FIELD P.C.CONC. EL.97.0
CHECK SEPTIC TANK(F1- 10) GASBAFFLE o
G'MIN.
,t 6eaaDo et EL.97.5 a°po n EL.97.3 e"bOo88 EL.95.0
ov, ob
`—W CRU5HED STONE OR COMPACTED J 3/4'TO 1 I/7_'D011fit.T:
_ 2 MIN. I 5'MIN: WASPICU STONE
DEPTH OF LIQUID-4 IIIII mo— --1rr
INLET TEE DEPTH- 1D-
OUTLET TEE DEPTH. 14• I U UI.I()W
PROFILE OF DISPO5AL 5Y5TEM
(DRAWING NOT TO SCALE)
TOWN OF BARNSTABLE V
LOCATION 41 &A.Dm R�J 1/5;� SEWAGE # 3 s�
VILLAGE ktJ 01 S ASSESSOR'S MAP& LOT 9 — I 1 S-
INSTALLER'S NAME&PHONE NO. T/rWt.is3 4t•LeX— %Qg-42D . OZ-gQ
SEPTIC TANK CAPACITY 15"D
LEACHING FACILITY: (type) (size) 7 F3Br1
NO.OF BEDROOMS 3
BUILDER OR OWNER ep-1 c, P1 LOWS
PERMTTDATE: ? ZZ"S COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility 7 I 0 Feet
Private Water Supply Well and Leaching Facility (If any wells exist Al
/
on site or within 200 feet of leaching facility) 'U D�� Feet
Edge of Wetland and Leaching Facility(If any wetlands exist 0�'�
within 300 feet of leaching acility) Feet
Furnished by PL
IZ) ® O d 6` cvp
6�
N
�-
I
No. C Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
es
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01pplication for ZigpOgar *p$tem Con5truttion Vermtt
Application fora Permit to Construct( . )Repair( i4upgrade( )Abandon( ) ❑Complete System El Individual Components
Location Address or Lot No. /�i S U 0 W�1 �1 /Li(� Owner's Name,Address d Tel.No.
. 1 45Lie— VAol.w�'
Assessor's Map/Parcel ^/ y 1 s U O m l (7z, ";`
Installer's Name,Added Tel .L — nil, Lj��o2�j Design�s�Address and Tel.No.
P.D,Ba (- `74) tMA-a6TD1JS 1Mi L b , rwA �0 ,o, Box 99 0,S-4'?5wlcA MA
Type of Building: U#,S3 8'_13 4s /9
Dwelling No. of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building &9�i 1>L:i TILL No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 3 gallons.
Plan Date ZrU wl Z/_ O S— Number of sheets /' Revision Date /VO 1U e-
Title
Size of Septic Tank At6'W !S-OD Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) NI✓Lk) CIS?-E-( EUYM 62YAJ6AI10
ALIT
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 Envir nmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue by this Board of lth.
Signe Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Q-W 5 3 5 1 Date Issued ��
\W'�,. �., 1R�r.�•' f . ....t .tir.`:�Z.. J;.Ly�,- �.�1�a4``ti`�``L..,.��� „` vk "'. !�2 �� ....,.�. � .� rs •-� •,.. - � ..
AW 5 _ d
No �.!� I j Fee
I Entered in com uteri
THE COMMONWEALTH OF MASSACHUSETTS S.
p
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication' for Migb2ar bpotem Congtruction.permit
Application for a Permit to Construct( )Repair(✓)Upgrade(" )Abandon( ) El Complete System O Individual Components
Location Address or Lot No. S U O M 1 —D/Ll V Owner's Name,Address ¢Tel No y-t?.
L,�1C_ I� OOP
M ASP 269 I I y! s u o m l IZ ,
Assessor's Map/Parcel
Installer's Name,Addrand Tel jV�0. 8 L�� n7l'i� Designer's�Name,A dress and Tel.No. S�jj�'s 8��• �OL
BDX 70 2 1M A-R ry tjs N�1 t.LS ru PCP t o. Ro X 9 q L A w l ce-/ MA
Type of Building: 9437 -3 /9
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building Pal Da'IA'L No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 3 gallons per day. Calculated daily flow 3; gallons.
Plan Date;TV.L4/ 2/, 0 b— Number of sheets / Revision Date A)O RJ E-
Title
Size of Septic Tank Al a✓'-W S-0 D Type of S.A.S. L C X
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) I�E'w �filS'rEm pl2p yyl rD.I Al DkT�D
D i 1 r,
i
i. Date last inspected:
S,
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 Envir mriental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issue by this Board of a//11alth. •�1
Signe Date [ • �Z'
Application Approved bt44 Date -7 =RP` S
Application Disapproved for the following reasons
Permit No. c�-� 351 Date Issued Via- S
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the Op�- ite Sewage Disposal System Constructed( )Repaired (v ) Upgraded( . )
Abandoned( )by � rA 4 ens (-T oil-&-Z
at l Su 0/� 1 172111�� lei AT►NI$P1)2T has been constructed in ac ordance
with the provisi s of Title 5 d the for Disposal Sy tem Construction Permit No.0'O 5 3'5 I dated 7 s- 5
Installer A✓y1�5 / Ot.( L. Designer 1,A-0'rifX
The issuance of this permit •all of e o trued as a guarantee th� sy to 11 n on ae ig4Aed
Date Inspe�or
— Uw 5 3 5 I --------------------------Fee UQ
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Mi$pozal bp$tem Congtruction Permit
Permission is hereby granted to Construct( )Repair )Upgrade( )Abandon( )
System located at 41 su D rA I 1Dfu Vr
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: Constructio�usttbbe)ompleted within three years of the to of this 't.
Date:_��='�f Approved
i
°FINE A
Town of Barnstable
SST"M # Regulatory Services
y MASS. g
1639.�A.0 Thomas F. Geiler,Director
Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
July 19, 2005
Mr Eric Paone
67 Old Queen Ann Road
Chatham, MA 02633
NON-COMPLIANCE WITH STATE ENVIRONMENTAL CODE TITLE V.
The septic system owned by you located at 41 Suomi Road,Hyannis,MA was inspected on
May 5th, 2005 by Mark Polselh, a certified septic inspector for the State of Massachusetts.
The inspection of your septic system showed that your system has "Conditionally Passed"under the
guidelines of 1995 TITLE 5 (310 CMR 15.00)DUE TO THE FOLLOWING:
"Ponding observed 5" below invert" of leaching pit.
You have two years from the date of the system inspection to bring the system into compliance.
If there are any questions about this reminder,please feel free to contact the Barnstable Health
Department.
BARNSTABLE ALTH EPARTMENT
4COMMONWEALTH OF MASSACHUSETTS
E)CECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 1l�
DEPARTMENT OF ZMRONMENTAL PROTECTIONTITLE 5
P�
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY
SUBSURFACE SEWAGE DISPOSAL STEM FORM ASSESSMENTS
PART A
CERTIFICATION
Property Addrems: .SC40041" Ri
aco�
Owner's Name: . �N,
Owner's Addreau � —;
q q O Awn gel c„ o
Date of lnspecdon: 33 e7, �
Name of Inspector:Company Na pint) GJr w e,
Nan,,—.
Mailing Address: a Zz
Telephone Numbe �6u� e
CERTIFICATION STATEMENT co
I certify that I have personally inspected the sewage disposal system at this addrms and that the info below is hue,accmft training and experiencem c�omplete as of the time of the' inspection was performed iniatio��
p�nper hnctice and uance a ofo The' my
approved s,�inspector afon site sewage disposal systems.I am a DEP
pursu,mt to 3ettloa 15-M of Title 3(310 CMR 11000]L The system:
Passes
CmNonaffy Passes
Beds Further Evaluation by the local Approving Authy
Fails
Inspector's Signature:
Date: p j-
MW system inspector shall submit a copy of this inspection report to the
DEP)within 30 days of completing this inspection,If the system is a shared Jx0mg y(Board of Health or
Wd or! ,the inspector and the system owner shall submit the or has a design flow of 10,000
DEP.The original should be seat to the report a the appropriate b*an l office of the sty system owner and copies seat to the buyer,if applicab and the approving
Notes and Comments
""This report only describes conditions at the time of
time.This inspection does not address how the system
conditions of use. Perform in the dfutare under the same or different
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(
PrOIN ly Address: !/10
Owne
h� 6OJ
Date o r inspecdm.
mmuy: Check A,H,C,D or V./AL
Sa AYJ complete aD of Section D
T15O3,
'have not hund any
in31 C information which indices that anyoff&a��a�tled in 310 CMR
Any failru+e aiLeria not evahrat�are d below
Comm
B. y Conditionally Passes;
repaired.The ��System �nts as described in the"Conditional Pass"section need to be replaced or
sy�,�onmgletfon of the replacement or zq)*,as approved by the Board of Health,will pus,
Answ
MW
explain. no Of not determined(Y,N,ND)in the for the following statements If"not determined"please
Th septic
Panic is mew and over
as Or Years old*
or the
Septic tank(Whether metal or not)is gtruchnaffy,
jnmineng�System
ill
w 8 co b septic tank as app av by� boa if the
indicting that the tank is less pass�years old is av Haft
SWQCWndly sound,not l if a Certifipic of Cow
ND
Of sewage backtip or break out or hi
gh static water kvd in the disuixtion box due to brolm
RVWval Board of Health): settledobstructed p4*s)or due to a Wolmn, or uneven boa box. System wwal (withor
Woken pipes)are replaced
obanction is removed
diStibudon box is leveled or repLiced
ND explain.
reP"r'ed Burping more than 4 times a year due to broken a�
Pass inspecti if(with*Fuval of the Board of Haft), 0bsMWt0d PBe(s)•The system will
broken pipes)are reps
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(cor�moM
Property Address: .Sti 0
►1 d o�
Owner. o! 0i
Date of Inspection: 0
C. Fartber Evaluation is Required by the Board of Health:
AC0a"ons wcW which rcgmm fkAff evaluation by-the Board of Health m order to determine if the to Prow plc health,safely or the environment, system
L Systemwill Paw unless Board of Health deftyndneg in&word&=with 310 CMX 1&303(1)(b)that the
system is not functioning ie a manner which will prated public health,safety and the environment:
_ Cesspool or privy is within 50 fleet of a surface water
_ Cesspool or privy is within 50 fed of a bordering vegetated wedand or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that sY�Is functioning in a manner that protects the public bwtth,safety and environs the
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 I of a public water supply,
_ The system bas a septic tank and SAS and the SAS is within 50 feet of a private water supply,well.
IU system has a septic tank and SAS and the SAS is less than 100 fed but 50 feet of more from a
private water
SIF*well Method used to determine distance
"'ibis system passes if the well water
bacteria and volatile analysis,performed at a DEP certified laboratory,fat colifornt
°mac c indicates that the well is free from pollution from that fi3cility and
the presence of ammonia nitrogen and nitrate Bogen is egmd to or less than 3
failure criteria are triggered.A copy of the analysis MM be attached to this form provided that no other
3. Other.
' Page 4 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTEFICATION(continued)
Property L
pvh
Owner:Date of In
D. System Failure Criteria applicable to an systems:
You modindlc'ste'�►es"or`dad'to each of the following for a& ens:
Yes NoP
�C � nd'mwaV go filcilily or system componeW doe to averloadod or clogs SAS or cesspool
dSAS ceOf the a surface waters due to an overloaded or
S.126hQdd level in the dsftbutkm box above outlet invert due to an dverloadod ar'
clogged SAS or
depth in cesspool is leas than 6"below invert or available volume is less than K Sow
of , Pig more than 4 times in the last yew ( T due to clogged cr obstructed pp Xs) Number
portion of the SAS,Cesspool or privy is below high ground water elevation.
roppAgqmrdw�cesspool or privy is within 100 feet of a surface water supply or tributary to a smcf
am
Of a cesspool or privy is within a Zone 1 of a public well.
portion
of a cesspool or privy is within 30 feet of a private water supply MM
—,z Any partion of a cesspool or privy
supply well with a=Pb tie water q�inlz't�y tan bd&fed but S�II from a private water
P� at a DEP D' Passes If the well water analysis,eerdSed laboratory,for eoliform bacteaia and volat>!e organlc compounds
indicates that the wen is fun from
�.n pollution from,
that faetlity.and the presence of ammonia
nth%=is equal to or leas tban S PPnk provided that no other failure criteria
are triggered.A copy of the analysis most be attached to this form.]
Ile (Yes/No)The system Lqb I Have determined that one or more of the above
desraibed in 310 C1MIlt 1s.303,therefore the ��criteria e�as
�' fails.The system owner should Coact the Board of
Health to determine what will be necessary to Correct the failraee. .
E. Lag Systems:
To be considered a Iarge system the system mast serve a faciftty with a design now of 10,000 gpd to 15,000
You must indicate either"Yes"or"W to each of the following;
("he follown criteria V*to large systems m addition to the Merits above)
yes no
system is within 400 feet of a surEace drinking water supply
-- the System is within 200 feet of a tributary to a surface drinking water supply
abe�of a public water n"rogen sup well sensitive area(Interim wellhead Pwtmton Area—MPA)or a mapped
If you Have answered"yes"to any question in Section E the seem is co
"yes"in Section D above the �' ��a significant��or answered
si9nifcnnt threat under Section E r failed Aet ided
�or��r of any large system considered a
15.304.The system owner should contact the appropriate regional the
ms�ith 31a CIVIlt
iPaw S of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: J U O v�
Owner: G
Date otlnsprxtio>t: > 0/
Check if the following have been done.you most indictee es"or"ao"as to each of the followin
Yve
— information was reed by the ownw,fit,or Board of Health
— — Were arty of the system components pumped out in the previous two weeks
system received normal Bows m the
pevrons two week period
-- Have large volumes of water been i*uduced to the system recently or as part of this kgwt m
ere as built plans of the system.obtained and examined?r�:
(If they were not note as N/A) .
as the�Y at�g inspeed for signs of sewage hack up
as the site inspaxed for signs of bro k out
% em all system components,=dudiog the SAS,located on site
the sqft tank=mholm tummed,opened,and the interior of the tank higxcted for Me conditionof the or teems material of depth
constn,ct�,dumens<ona, of mod;depth of shKfp and depth of scam
U the balmy ownet(aced occupauft s f if differ om owner)provided with igIbrmation on the p oper sal;MAiae sewage-disposalzystems.
The size and locatlon of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no 57
— — bhrno'dm For example,a plan at the Board of Health.
Determined m the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)P10 CUR15.302(3)(b)j
• Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION'FORM
PART.0
SYSTEM INFORMATION
Property Addr+eam 4J
Owner.
Date of Inou:
R3�ID$NTIAL >iLOW C0NDI'1'L(fNS
Number of bedrooms(design): Number of bedno m(actual
DESIGN flow base 310
Nambr ofcu� esid ;�-15203(for aumpW 110 gpd x#of bedrooms)r
Does resideuoe have a garbage grinder(Yes or no):�
7 an a sqnrlft sewav hem(M or no):"[if yes separate im�n
Laundry system inspected(yea gr no).
Seasonal use:(yes or no):
water metes r J �2 years usage(g*):
i���or no):
ccupancy-
COIIA�RCIAL/INDIISTRIAL
Type of establishment:
Design flow(based on 310 MA I5.203): �.
Basis of design Saw(se"Prsons/sgft etc.).
Grease trap print(Yea or no):_
mdu mial waste bong tank p r, at(yes of no):
Non'sawtag waste discharged to the Tithe S system(Ves or no):Water _
Last date of ►¢avar�able:
occarpauq/uW,
OTHER(describe):
Pumping Records GENERAL INFO TION
Source of information:
Was system pumped as part of the Wpection(yes
Reyes,
se,vulum P=Ve& ealloes—How was quantity pumped determined?
TYPE SYSTEM
' tank distribution box,soil absorption system
_Shwa cesspool
Overflow Cesspool
—Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
obtained fiom systemrImMaWdAftanative t)echnology.Attach a copy of the current operation and conbW(to be
Tight tank _Attach a Copy of the DEP approval
_Other(desalt):
Approximate age of all COMPoner9K date installed(if lmown)apd source of ma on:
1( Ccnon/ 2 /Ydo1
Were sewage odors detected when arriving at the site(yes or no):/�
. Page 7 of 11
OFFICIAL INSPECTION FORM-NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.0
!� SYSTEMiINFORMATION(co�mmo
Property Ldd,nw / , 15C.011.7, �J
�nrlU
Owner,Date of Inov Q
BUILDING SEWER(locate.on site pin)
Depth below grade;
Materials of oonsaadtionc iron o Fvc
)idOOC M RM supply weg ar s —Otbff
;
(on rondition Of jam;VPfigevidence of I r
SEPTIC TANK;_:�7;M�Mae*
site )
Depth below grade:
Materialofcons�'o
other(explam) -- _polyethylene
Htankis metal listage:_ is
cer�rate) age d by a C /tea of C,omplianoe(yea or no):0 _(a /�a copy of
-� �'a►/God �• "� *10 A e-
�.t fe
slam b of amlet tee:air baffie:d ' T y�—k" . - syct,i'7
Distaaoe rmm top of scan,.to top of oadlet tee.��tr
a4
HoD� ontlet tee baffie:
C �(nudp.e :WVCK 1 ems►mlet k . an)d tee or ba$le stinxtwW integrity;liquid levels
`�,•�, „' mod c4-�L ��f
Lem Ze 641
-Oti
�1 0
_
GREASE TRAP..&"on site plan)Depth below _
grade:Material of e°nstracti°n'—°ora to�l_fibrglass—P*ethykne
( ): —Othff
Dimensions:
scum wda>ess;
Distance from top of scam to top af Ou let tee or baffie:
Date of last g of scam to bottom of outlet tee or beffieComments
��toto(ooutlet inyertg leakage etc outlet.tee or baffle condition,structural.integrity,liquid levels
Page 8 of 11
OFFICIAL INSPECTION FORM=NOT FOB VOI;UWARY ASSESSMC TS
SUBSURFACE SEWAGE-DEMSAI.SYSTEM INSPECTION FORM
PART.C
`SYSTEM INFORMATION(oo
Property Address: —T� ✓cr ova^
'� f
Ownw. �
Date of hupecdw:
TIGHT or HOLDING TANK:&:f,(tmk mud be pumped at time of iaspecti.X[.ft os site plan)
Depth below►grade:
Material of oonsbr. c concrete metal __polyethylenia
Dimen
s:
gin Flow;.
Alarm pnoenf(yes or no):
Alarm level; . Alarm in vwrling o.(,,es or no):
Date of last pumping
Comments(condition of alarm and&at switches,etc.):
DOTMUMON BOX (if pnSent mnst be ope>Wocate on site plan)
Depth of liquid level above oudd invert:
Comments(note if boar is level and 41lution to outkets equa%any mdeme of solids carryover,any evidence of
leakage into or OW of box,etc.):
PUP"CHAMBEX-&00catc on site plan)
Pumps in working older(yes or no).
Alarms is wading order(yes or no):
Comments(fie ooDMM of pump chamber,oandidOu of pumps and*Putamancc4 etc.):
PA-V9of11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSEMMME M
SUMURFACE SEWAGE-DLWSAL SYSUM V3 tMON FORM
/ SYSTEM. NitORAt&Nom(ooer ewi;
Pnverty Addmm,
Owner: o 0 VIc /
Date of In;WKM— 7
SOEL ABSOR SVSTgM(SASS: . Pam, stioi awt.rem
If SAS not locatedeg4m whr
a ,�:
sue , :
�laa► :
of
tw
cammetc): �� � // � ,oondaion��e�
o. '
it
(oes�ool rst be PWpod as part of invm ianXlocm on site Plan)
Numberaadao
Depth-rop of l�nid�a inld iave:t: .
aloft
Maw dommuctiom
Comma
kvd ofPondeeg mdbm aft a"t.
PRIM'�m sme vim)
Maceoal$doaostrocdo,�
Dimeasiormc
Dep&oft
Comments(note mndlEion ar
soff.sus of li3' lei ofpmdn cmaim ofvcffijatM eta):
Y
,
.• Page 10ofII
OFFICIAL INSPECTION FORM—NOT.FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION t
Property Addn= �t S� o -,r ,
NAc
Owner. �10 K, 61'
Date of Inspecdow c ��
SKETCH OF SEWAGE DISPOSAL,SYSTEM
Provide a stretch of the sewage disposal system iWjudiing ties to at least two permanent reference landouft of
benchmarks Locate all wells within 100 feet.Lorate where pabhc water sapply cum the
IJ
i
� O `
. 02
��-- a3 '
dq
r ,1• .
• • ., a Page 11 of 11
o
. OFFICIAL INSPECTION FORAM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/L SYSTEM INFORMATION(comimn
Property Address:
Owner: ��o O
Date of hopes: r j
SITE EXAM
Slope
Surhm water
Check cellar
Shallow►wells
fJ /
Fnatod ft&to 1mmd war/o` feet
Pleasec�6e(deck)all methods used to detemune the h*hsmwd water elevation;
( skm V m�chemn 1 date of design Fig
C wdood wish hx:d Board of Health exxp�in: wrthra l so feet of SAS
Chedmd U A ens-(attach docu �)
You mnst YOU
h%l►groead wagter eJevatioa• i
a.. q fo �
O r 0�rSA Jwc�ry.
v !i.
i
Town' of Barnstable
Regulatory Services
Thomas F. Geiler, Director
• swxNsrnsc,E,
9�A 'b 9 A�O Public Health Division
'Eo►r+At Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer &Designer Certification Form
Date:
Designer: Installer:
�� , 3�J �'� P i D , 15bje, '742—
Address: Address:
' /
On �Z�u 01 1�VS 4VLL9was issued a permit to install a
j (date) . (installer)
o
septic system at ''� � cJ V M � ,� ``� -T�14 XI-'based on a design drawn by `
(address)
L L 141 1 C�� 1 - ' dated c
� ) � ®.
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
or
(Installer's Signature) L N
c� LANTERY, 1R. cai
o.2 1 p N6575 p
P � � F
C/STEPG�4,
AA
\ SS/ONAI EN
(Designer Signature J (Affix Designer"'s Stamp Here)
PLEASE RETURN,TO B STABLE PUBLIC BEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
Town of Barnstable
Department of Regulatory Services
= F Public Health-Division DateMASS
200 Main Street,Hyannis MA 02601
. !/d Fee Pd V
• Date Scheduled Time . •
Soil Suitability Assessment for Sewage Di osal
Performed By: I'� 2'1"t(V witnessed By: ���
LOCATION&GENERAL INFORMA
Location Ad Owner's Name
S� � Address
• Assessor's Map/Parcel: L R _ Engineer's Name sL t
NEW CONSTRUCTION y 111 REPAIR Telephone# 0
Land Use -0 VSl jlz� Slopes M Z + e Surface Stones' '
• 1'
Distances from: Open Water Body 0 ft Possible Wet,zf W A-J ft Drinking Water Well ft
Drainage Way '�6 ft Property Une �_ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&pert tests,locate wetlands in proximity to holes)
0 V
cL
Parent material(geologic) Dep'At to Bedroek
Depth to Groundwater. Standing Water in Hole: ' v - weeping from Pit Face V '
Estimated Seasonal High Groundwater
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: in. Depth to soil mottlos: in.
Depth Observed standing in obs.hole:
Depth to weeping from side of obs.hole: in. ,Groundwater Ac�lustment
Index Well# Reading Date: Index Well level Adj.Aaetar,.,ea AtQ.Groundwater Level
- - PERCOLATION TIES' ]Help
Observation lime at 4"
Hole#
Depth of Perc Time at 6" �.�..
Start Pre-soak Time @ _G---'=—', '15me(9"-6") --- -
End Pre-soak
Rate MinJlnch t
Site Suitability Assessment: Site Passed � Site Failed: _ Additional Testing N�eded(M
P r'•'
Observation Hole Data To Be Completed on Back
Original: Public:Health Division r
C
***If percolation test'is to be conducted within 100'of wetland,you must'first notify the.
Barnstable Conseirvation Division at least one(1)week prior to beginning.
Q:\SEPn0PERCF0RM.DOC i
DEEP-OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture .Sdil Color Soil- Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistency. -v
1w ,-CS . 2 Y64 sex
DEEP'OBSERVATION HOLE LOG
Depth from t (VA Soil Horizon`k .• Soil Texture Soil Color Soil ,Other
Surface I%- (USDA) (Munsell) Mottling I (Structure;Stones,Boulders.
; _t , F _\.fir t'. • Cpns' n %
AM'M S. -Ad D
_ -
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color. Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
ConsistenmOmvcll
DEEP OBSERVATION HOLE LOG Hole#
• Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling • (Structure,Stones:Boulders„)
Consistency.
i
Flood Insurance Rate Map:
Above 500 year flood boundary No Yes
within Soo year boundary No Yes
within too year flood boundary No— Yes
t.
Depth of Naturally Occurring Pervious Material 1�= �-
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
area proposed for the soil absorption system? < ' ' '✓
If not,what is the depth of naturally occurring pervious material?
Certification
I certify that on '6� A. , (date)I have passed the soil evaluator examination approved by the
Department of En ironmental Protec'on and th above analysis was perfo y me consistent with
the requir i ,experts and a ence d c in 10 CMR 15.01
Signature Da
Q.WEpTIC1PBRCFORM.DOC
r ^ A
ll
``� i
TEST PIT PERC. TLST S
�� ; �16'
EXISTING ' r�
# 1 GRADE # 2
LCl ! 1328 100.0- - 100.0
99.1 - SANDY LOAM - 99.1
97.5 - LOAMY SAND 97.5 '
` LOCUS MAP
PERC RATE <
2 MIN / IN. DESIGN
MEDIUM SINGLE FAMILY DWELLING W13 BEDROOMS
COARSE SAND NO GARBAGE DISPOSAL
AND GRAVEL DAILY FLOW = I 10 X 3 = 330 G.P.D.
SEPTIC TANK(VOL. REQ'D)
rn 330 G.P.D. X 2 = GGO GALS
1,500 GAL. TANK-O.K.
O� ,plf
90.0 - NO WATER - gp.p LEACHING AREA(5.A.5.)
1 USE 4 - 3'X G'X 2' P.C. CONC. L.C. +4'STONE ON END
0.0' 14 5, �. I., ,��� � 3.5 ON SIDE
rn v_ ,I � EFFECTIVE DEPTH = 2.0'
--� 100' - TESTED : 07/18/05 2 X [G4 + 26] X 0.74 = 124
B .
p D. . - _ <f c,p
p S.T. 5.0' ' I.-
,`, IOX32X0.74 = 237
3 2.0' / 10.0' j ' x
1 TOTAL CAPACITY = 36 I GALS.
r rn 1 I NOTES:
17.0 / No 4 I
rn I I, G
5TY. ,
1 . DISPOSAL SYSTEM TO BE CONSTRUCTED IN STRICT ACCORDANCE WITH
10.0' 40 mil / 1 51' FL. - 103.3G COMMONWEALTH OF MA55ACHU5ETT5 ENVIRONMENTAL CODE -TITLE V.
BARRIER r I 2. ASSESSORS PARCEL NUMBER (APN) : MAP 2G`� - PC. 1 15
/___.1�� I 3. CONTRACTORS TO CALL DIG--SAFE 72 HOURS PRIOR TO BEGINING CONSTRUCTION AND/OR EXCAVATION.
4. EXISTING PITS TO BE PUMPED AND FILLED WITH ',AND, AND ABANDONED.
5. CONTRACTOR TO FIELD CHECK INVERT OF EXI 1 , TAv'K
G. IJ5E 1 500 GALLON SEPTIC TANK WIT!-1 T'a f ^ -,'c �'
L_� -C ivi-\'JL I I I LC V.
ilAN DGE5 NOT, iiN ANY WAY, KEPRE5ENF AN ACCURATE, !NSTRU[,,"E'JT 5URvfY OF THE PROPERTY, AND 15 NOT
\' TO BE U5ED FOR ANY CONSTRUCTION, OTHER THAN THE ELEMENTS OF THE SEPTIC SYSTEM A5 SHOWN.
5. TH15 PLAN 15 NOT A RECORDABLE PLAN.
\ 9. BENCHMARK 15 BASED ON AN A55UMED DATUM, A5 SHOWN, UNLESS OTHERWISE SPECIFIED.
10. 5UVREYOR: HOOD SURVEY GROUP, LLC: P.O. BOX 23 1 : SANDWICH, MA 025G3
j 1 1 . U5E 4 G' X 3' X 2' P.C. CONCRETE LEACH CHAMBERS W 4' OF 3/4" - 112" DOUBLE WASHED STONE ALL AROUND
\�\
� EDGE O�' n Ii i WITH 2 " OF PEASTONE ON TOP.
1 2. PLACE 40 MIL BARRIER BETWEEN HOUSE FOUNDATION AND SEPTIC LEACH FIELD.
13. THI5 BARRIER WILL ALLOW FOR A REDUCTION FROM 20' - 1 7 FROM HOUSE FOUNDATION
TO EDGE OF LEACHING AREA.
14. THI5 REDUCTION REQUIRES A VARIANCE FROM THE HEALTH AGENT.
yy b'._
OF,y ���tN OF MgSSIC
c� �= HARRY ��sG ���� RIC HARD
5 I T F F IJA N o
FIRST FLOOR EARL c� HOOD U'-EL. 103.36 LANTERY, No. 35031
P No 26575 0 to _p O �o
TOP OF WALL BRA+�. SSG I S T
EL. 101.0 N
i a
FIN. GP. EL. 100.070�7 -EXISTING GR. EL. 454.0 2^' 5 O7FF jr7 77 -77r 7 �7�r
Tr..'T T��� �\ \ \ \/\ \ Tj\T\/\/\/\J\T'\%. 7k �/�/\/i��� \7/�Tj,.'/�/\"!' T/\/�Z l
ACCESS W/IN 6"OF GR.�77�7 \\ \j/\\/\\i\\i\�%\\i?,i\\i\\i\\i\\i\\i\\:;� \i\\�\\Ml�ail \A��\y:c �\ \\i\\\i\\i\\i, \i\\i\\i`:ice:• i\\i\\i\\i,
SEWAGE SYSTEM DESIGN
9'MIN. COVER /
FIELD _ \\ I F f l�SI ONE AC
CHECK F
/ 98.3 H2O TEST FOR
OR
[OR LEVEL /
EL. 98.0 1,000 GAL EL 97.7 - `2'LEVEL - _ J+ _ . 13
/ D-Box l �I.. 97.0 ,r� HEALTH AGENT APPROVAL DATE E RI C PAO N E
P.C. CONC. 4�cYr c`
/ FIELD -- r`W, r.
CHECK SEPTIC TANK(H- 10) GA5BAFFLE
6"MIPJ. J �•��� uao, FI-. ��_.o_ °; Sb ���
O N
EL. 97.5 " ' LEGEND
g°i a ve of oopPo ���98
�-6"CRUSHED STONE OR COMPACTED-� W!,'�f •T�_ u[ _
5U0MI DRIVE a',�i✓i
MIN- -� 24 PROPOSED CONTOUR
DEPTH OF LIQUID-4' 20'MIN. HOOD SURVEY GROUP, LLC. A . T . 5 .
�
OUTLET TEE DEPPTH 1014" - - -i 1,(? I st I r r,, / 10 �� EXISTING CONTOUR LAND SURVEYORS CONSULTING ENGINEERS
DRIVEWAY 18 ROUTE 6A P.O. BOX 99
SANDWICH, MA 025G3 E. SANDWICH, MA 02537
PRO1 11-If OF FX-J � ,'5AI_ SYSTEM licit
FIRM ZONE DATE: 2 1 JUL05 SCALE: I" = 20'
( DP,AWIN!; H01 IC) 5CALE ) °Bit