HomeMy WebLinkAbout0044 SYLVAN DRIVE - Health y ire _
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No. ^` Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
appYitation for Nsposai 6pstem Construction 3permit
Application for a Permit to Construct(Vj-'*`Repair( ) Upgrade( ) Abandon( ) 0 Complete System ❑Individual Components
Location Address or Lot No. 7 q sy IVp(.,, at ive_ Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel 5-6 8 cP i ScowN 16 771 --rb 96
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
Q�1 ns 1,11 77Y3s2c�g
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) n/Q(,,) 0 26 D "S S 0 Sox
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 t e E ironmen Cod and not to place the system in operation until a Certificate of
Compliance has been issued by..this oar f ealt
4giied r-- Date 6 //7
Application Approved by, Date �/ /
3
Application Disapproved by Date
for the following reasons
Permit No. `40/ 7 —/?d Date Issued � /
a No.,!P / 7 Fee
7
•
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftpliLation for Disposal *pstem Construction Permit
r
Application for a Permit to Construct(Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. q / St jva n f lve Owner's Name,Address,and Tel.No.
n�rnis
Assessors Map/Parcel _ 6
SL V sH i n (ow N S6A 7-71 -so 96
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
44
7 y 3T2a0g
Type of Building: 4'
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Qy Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
4
Description of Soil t
i
Nature of Repairs or Alterations(Answer when applicable) n/p(,) D p S 1) BOX
1 •
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 e E vironment Cod and not to place the system in operation until a Certificate of
Compliance has been issued by this BoaraX .ealt
S geed r-- Date G 7
Application Approved by' Date
Application Disapproved by Date
for the following reasons
l
/ Permit No. ;�),0/ 7 —/7d Date Issued
r
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(vl) Upgraded( )
Abandoned( )by
at L)y S j1 y4r\ : /;LIP has been constructed in accordance
with the pr visions of Title 5 and the for Disposal System Construction Permit No�V7�-176 dated
Installer �v;n p 5 Pica yc4 icy Designer
#bedrooms Approved design flow gpd
The issuance of this permit shall not be construed as a guarantee that the system will-function as esjgned.
Date 1'0/1/l� Inspector ��i�r----��
No. (D -7 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Disposal 6pstem Construction i3ermit
Permission is hereby granted to Construct ) Repair(V) Upgrade( ) Abandon( )
System located at y q S /VGn / f 1 k
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Con truction must be completed within three years of the date of this pe it.
Date__ 7 Approved by
i
�. Town of Barnstable
• �xsraar.E, •
1 ,�� Regulatory Services Department
Public Health'Division
200 Main Street,Hyannis MA"02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A McKean,CHO
Feb 6, 2007
Rev. 5/11/16
DEADLINES T.OREPAIR 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 (1)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).
TWO (2)YEAR DEADLINE CRITERIA
q Single Cesspool
❑Any"conditionally passed systems" (broken cover,relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑Leaching 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:
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
7M 44 Slyvan Drive ;
Property Address IQ
Q
Bettina & Lawrence Brown
Owner Owner's Name
information is X
required for every Hyannis t✓ Ma. 02601 05/26/2017 �-4
page., City/Town State Zip Code Date of Inspection
F�
I-+
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 forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael T Bisienere
use the return Name of Inspector
key.
Cape Septic Inspections
� Company Name
624 Old Barnstable Road
Company Address
Mashpee Ma. 02649
Citylrown State Zip Code
508-280-3356 Si3938
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
05/27/2017
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 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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
' ~ Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is required for every Hyannis Ma. 02601 05/26/2017
-
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is required for every Hyannis Ma. 02601 05/26/2017
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 H-10 D-Box is not structuraly sound and needs to be replaced.
❑ 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 pipes) 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
l5ins.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
M 44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is required for every Hyannis Ma. 02601 05/26/2017
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 cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is Hyannis Ma. 02601 05/26/2017
required for 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.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
F . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is required for every Hyannis Ma. 02601 05/26/2017
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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR.15.203 (for example: 110 gpd x#of bedrooms): >330
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pagi 6 of 17.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w •'` 44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is Hyannis Ma. 02601 05/26/2017
required for every Y
page. City(rown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
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)):
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 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
44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is required for every Hyannis Ma. 02601 05/26/2017
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: The tank was pumped in March 2017
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is required for every Hyannis Ma. 02601 05/26/2017
-
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
new leaching installed in 1994
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
"
Depth below grade: 21feet
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.):
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
s
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: Standard H-10 1000 gallon septic
tank
Sludge depth:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 F
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is required for every Hyannis Ma. 02601 05/26/2017
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
36"
Scum thickness 1
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
12"
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.):
I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The
Barnstable Health Dept. has a list of local septic pumping co.
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
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is required for every Hyannis Ma. 02601 05/26/2017
page. Cityrrown 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 ❑ other(explain):
Dimensions:
Capacity: gallons
I
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
I
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.6/16 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
µM 44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is Hyannis Ma. 02601 05/26/2017
required for every y
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.):
The H-10 D-Box is not structuraly sound and needs to be replaced.
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
44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is required for every Hyannis Ma. 02601 05/26/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 2
❑ leaching chambers number:
❑ 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.):
At the time of the inspection one of the leaching pits was dry and the other had appx. 2 feet of
ponding water.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
I
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
,M 44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is Hyannis Ma. 02601 05/26/2017
required for 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.):
I
t5ins.doc•rev.6/16' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is required for every Hyannis Ma. 02601 05/26/2017
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
� s 3
j, fJ 41- ti e:,I--7- %�k7 e,
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page,15 of 17
TOWN OF BARNSTABLE
LOCATION I sY�f/.�d2i � SEWAGE # ,5's�s
VILLAGE HUgtln m ASSESSOR'S MAP Q LOT;9j? -Q1-112
INSTALLER'S NAME& PHONE NO.;77-
SEPTIC TANK CAPACITY19D0
LEACHING FACILITY4t-ype)y,7 /��f g (size) /dOQ
NO.OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER
BAR OR OWNER V0h y ldq 11-1111t/Sao/
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes NaZ
I
OL v
i
i
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is required for every Hyannis Ma. 02601 05/26/2017
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: 14 plus feet
feet
Please indicate all methods used to determine the high ground water elevation:
I
❑ 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:
I augered a hole at lower elevation and shot it with a transit.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l5ins.doc•rev.6/16 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
44 Slyvan Drive
Property Address
Bettina & Lawrence Brown
Owner Owner's Name
information is required for every Hyannis Ma. 02601 05/26/2017
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System-either drawn on page 15 or attached in separate file
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
I-- u/5
COMMONWEALTH OF MASSACHUSETTS
s EXECUTIVE OFFICE OF ENVIRONMENTAL•
? DEPARTMENT OF ENVIRONMENTAL P O�IV ®'
ONE WINTER STREET, BOSTON. MA 02108 61 7-292-5 0o J U L 2 5 199T
' HEALTF QLPT.
WILLIANI F.WELD TOWN OF QARNSTAGLE T UDY COXE
Governor Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION
Property Address: 44' Sylvan. Dr, Hyannis Address of Owner:Norma Atkinson
Date of Inspection: 7—;` -3— Q1'7 (If different)
Name of Inspector: Wm E Robinson Sr
I-am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Wm E Robinson Septic Service
Mailing Address: PO Box 1089 , Centerville, MA 02632
Telephone Number: 508 775-8776
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
�sses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ fails
Inspector's Signature: 4 Date: /` � 7
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, Or D:
AI SYSTEM PASSES:
�'1'have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
MMENTS:
BI S STEM 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.
/,dicate yes, no,.or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web: http:11www.magnet.state.ma.us/dep
r, eJ Printed on Recycled Paper
B
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SUBSURFAC';: SEWAGE DISPOSAL SYSTEM INSPECTION FORM
-= PART A
CERTIFICATION (continued)
Property Address: 44 Sylvan Dr, Hyannis
Owner: Norma Atkinson
Date of Inspection: -7Z23'^47 '7
' T I
B] YSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
C] FURT ER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
i
C nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
p blic health, safety and the environment.
1) SY TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
W ICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.'
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. ;
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
(revised 04/25/97) Page 2 of 10
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 44 Sylvan Dr, Hyannis
Owner: Norma Atkinson
Date of Inspection: 7—;-3--�
D) SYSTEM FAILS:
o must indicate ei; ,er "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Yes No
-Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped _.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
EJ LARGE SYSTEM FAILS:
Y u must indicate either "Yes" or "No" as to each of the following:
The'following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a
public water supply well)
T e owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
r quirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
I
I
SUBSURFACE SEWAGE.DISPOSAL SYSTEM INSPECTION FORM f
PART B
CHECKLIST
yS
I, I
Property Address: 44 Sylvan Dr, Hyannis ,E
Owner: Norma Atkinson
Date of Inspection: /f
t �
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal E
flow rates during that period. Large volumes of water have not been introduced into the system recently or F
j as part of this inspection.
As built plans have been obtained and examined. Note if they are not available with N/A.
f.
The facility or dwelling was inspected for signs of sewage back-up. f '
The system does not receive nor.-sanitary or industrial waste flow.
The site was inspected for signs of breakout. o
a�
All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank m;inholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on: "
The facility owner (and occupants, if different from owner) were provided with information on :he proper maintenance 0ff
v' Sub-Surface Disposal System.
' I
7�S _ Existing information. Ex. Plan at B.O.H.
i
I L�:y _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b)) f
i1.
Y
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(revised 04/25/97) Page 4 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 44 Sylvan Dr, Hyannis
Owner: Norma Atkinson
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design fIow:il-19—g.p.d./bedroom for S.A.S.
Number of bedrooms:
Number of current residents -
Garbage grinder (yes or no):_/LC
Laundry connected to system (yes or no):V' L�
Seasonal use (yes or no):Ac_0 T—
Water meter readings, if available (last two (2) year usage (gpd): 1 2 y4 0 0 rcu.`.f.t 1 9 9 5 9 3 , 0 0 0 gal s
Sump Pump (yes or no):,k o 1 2;400 cu ft 1996 93, 000gals
Last date of occupancy:� 3^°/ f7
COMMERCIAL/INDUSTRIAL:
Type`a establishment:
Design w:_gallons/day
Grease tr p present: (yes or no)_
Industrial aste Holding Tank present: (yes or no)_
Non-sanit ry waste discharged to the Title 5 system: (yes or no)_
Water m er readings, if available:
Last date of occupancy:
OTHE . (Describe)
Last d of occupancy:
GENERAL INFORMATION
PUMPING RECORD and source of information:
System umped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF STEM
_ 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)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information: 6 aA
Sewage odors detected when arriving at the site: (yes or no)40.
(revised 04/25/97) Page 5 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Sylvan Dr, Hyannis
Owner: Norma Atkinson
Date of Inspection:
B ING SEWER:
(Locate on site plan)
Depth b low, grade:
Material of construction: _cast iron _40 PVC _ other (explain)
Distan a from private water supply well or suction line
Diamet r
Comm nts: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK:v
(locate on site plan)
Depth below grade: 0 t
Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age — Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions: � I r, G 4 4 �-
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle: *0
Scum thickness: ;L-3 ' t t, ti .
Distance from top of scum to top of out tee or baffle: � ) ,
Distance from bottom of scum to bottom of outlet .ee or baffle:
How dimensions were determined: 4 ie sa R J 5
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of h uid level in relation to outlet invert, structural r:
integrity, evidence of leakage etc.) 612-0
� ot� ea
GREASE RAP:
(locate on ite plan)
i
Depth belo grade:
Material of onstruction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensio
Scum thi ness:
Distanc from top of scum to top of outlet tee or baffle:
Distan a from bottom of scum to bottom of outlet tee or baffle:
Date of st pumping:
Comment
(recomme dation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural f
integrity, vidence of leakage, etc.)
"i
3
(revised 04/25/97) Page 6 of 10
c,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Sylvan Dr, Hyannis
Owner: Norma Atkinson
Date of Inspection:
TICyHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(looat on site plan)
Depth low grade:
Material construction: _concrete _metal _Fiberglass _Polyethylene _other(explain)
Dimensio
Capacity: gallons
Design fl w: gallons/day
Alarm le I: Alarm in working order_Yes; _ No
Date of pr vious pumping:
Comments
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: /
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) b
PU CHAMBER:_
(locate on site plan)
Pumps i working order: (Yes or No)
Alarms working order (Yes or No)
Comm ts:
(note ndition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 04/25/97) Page 7 of 10
rt ;
. y F
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) i ti
Property Address: 44 Sylvan Dr, Hyannis
Owner: Norma Atkinson
Date of Inspection: 12^X3--517
SOIL ABSORPTION SYSTEM (SAS):v
(locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
, a
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,Iength: a
leaching fields, number, dimensions: J — 16- 3 d
overflow cesspool, number:
Alternative system:
Name of Technology:
i
Comments:
(note condition a`f soil, signs of hydraulic failure evel of ponding, condition of vegetation, etc.)
C SPOOLS: _
(loca on site plan)
Num r and configuration:
Dept -top of liquid to inlet invert:
De of solids layer:
Dep h of scum layer: `
Di ensions of cesspool:
Mat rials of construction:
a .
Indi tion of groundwater:
inflow (cesspool must be pumped as part of inspection)
i
Col
ents:
note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
IVY: _
(Io to on site plan)
Mat rials of construction: Dimensions:
De th of solids-.
Co ments:
(n to condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
t
(revised 04/25/97) Page 6 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 44 Sylvan Dr, Hyannis
Owner: Norma Atkinson
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into ho se)
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(revised 04/25/97) Page 9 of 10
r
;ct SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION"FORM ,
PART C
SYSTEM INFORMATION (continued)
t''roperty Address: 44 Sylvan Dr, Hyannis ,
't�'Owner: Norma Atkinson
J Dete of Inspection: �3 Qi 17
•'it � •
Depth to Groundwater /a Feet
Please indicate all the methods used to determine High Groundwater Elevation: 4
Obtained from Design Plans on record
Observation of Site (Abutting property, observation hole, basement sump etc.)
' Determine it from local conditions
t
bV
Check with local Board of health-.
t ,
:.'::Check FEMA Maps t
Check pumping records
Check local excavators, installers
Use USGS Data
Describe,-,in your own words how you established :he High Groundwater Elevation. (Must be completed). i
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(revised 04/.25/97) - ; Page 30 0f 19trl-
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