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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (front unit)
Property Address
Roger Wharton
Owner Owner's Name ,
information is Hyannis Ma 02601 _ 4/30/2021
required for every State Zip Code Date of Inspection
page Cityrrown
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. Inspector Information 5 1 S 35
on the computer, -Sean M. Jones
use only the tab
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection _
use the return Company Name
key.
74 Beldan Lane
Company Address
Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com, S14522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 16.000);1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined
that the system:
1. ® Passes .
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
4/30/2021
Inspector's Signature Date
The system inspec 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.7QW018 Title 6 Official Inspection Form:subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (front unit)
Property Address
Roger Wharton
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every
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:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
The property located at 44 Tevyaw Rd Hyannis front house is served by a Title V septic system
consisting of a 1000 gallon septic tank,distribution box and a 1000 gallon leach pit.Although the
system was found to be in proper working condition at the time of inspection this report does not
guarantee future performance under similar or increased usage.
2). System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
"A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5insp.doc•rev.7126/2018 Tdle 5 official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (front unit)
Property Address
Roger Wharton
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every
page. Cityown 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.712612DI8 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road front unit)
Property Address
Roger Wharton
Owner owner's Name
information is Hyannis Ma _ 02601 4/30/2021
required for every City/Town state Zip Code Date of Inspection
page.
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must Indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool r
t5insp.doc•rev.7/26/2016 Title 5 Official.lnspection Form:Subsurface Sewage Disposal System•Page 4 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (front unit)
Property Address
Roger Wharton
Owner owner's Name
information is Hyannis Ma 02601 4/30/2021 _
required for every State Zip Code Date of Inspection
page. Citylrown
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
El ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than'/day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
El ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000 gpd-
010,000 gpd.
El ® 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
El El Area
system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone ll of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 official Inspection Fonn:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
_44 Tevyaw Road(front unit)
Property Address
Roger Wharton
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every State Zip Code Date of Inspection
page. Ctty/Town
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 an 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?
® system stem received normal flows in the previous two week period?
❑ Has the
Have large volumes of water been introduced to the system recently or as part of
❑ ® this inspection?
® El available
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)]
f5insp.doc-rev.72=018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Tale 5 Official Inspect
ion
n Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (front unit)
Property Address
Roger Wharton
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every - State Zip Code Date of inspection
page. Citylrown
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 2 — Number of bedrooms(actual):
2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
220 gpd
Description:
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑
Yes No
current _
Last date of occupancy: Date
t5insp.doc•rev.7r26=8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
_ 44 Tevyaw Road {front unit)
`l Property Address
Roger Wharton
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every State Zip Code Date of Inspection
page. City/Town
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/personslsq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Tank pumped for inspection
Source of information:
Was system pumped as part of the inspection? ® Yes ❑ No
1000
If yes, volume pumped: gallons
How was quantity pumped determined? size of tank --"
routine maintenance.
Reason for pumping:
t5i sp doc rev.7126=18 Title 5 Official Inspection form:subsurface sewage Disposal System•Page 8 of 18
f
Commonwealth of Massachusetts
rA Title 5Offici
al Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (front unit)
Property Address
Roger Wharton
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every y State Zip Code Date of Inspection
page. Cityfrown
D. System Information (coot.)
4. Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
system installed 1995 per town records _
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):.
1.5
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting, evidence of leakage, etc.):
Joints in good condition, no leakage, vented through roof.
t5insp.doc-rev.71262D18 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 9 of 18
1
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (front unit)
Property Address
Roger Wharton
Owner Owners Name
information is Hyannis Ma 02601 4/30/2021
required for every � state Zip Code Date of Inspection
page. City/Town
D. System Information . cont.)
6. Septic Tank(locate on site plan):
1
Depth below grade: feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
1000 gallons
Dimensions:
5"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
3'
2"
Scum thickness
Distance from top of scum to top of outlet tee or baffle 711
10"
Distance from bottom of scum to bottom of outlet tee or baffle
T
Opened covers and took
How were dimensions determined? measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tank was pumped for inspection and should be done again every 2 years for proper maintenance.
Water level was even with outlet,tank was structurally sound and not leaking.
t5'arsp.doc•rev.726/2018
Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,. 44 Tevyaw Road front unit)
Property Address
Roger Wharton
Owner Owner's Name
information is H annis Ma 02601 4/30/2021
required for every y
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.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day '
t5"uW.doc•rev.7QW018 ritle 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (front unit)
Property Address
Roger Wharton
Owner owners Name
information is Hyannis Ma 02601 4/30/2021
required for every state Zip Code Date of inspection
page. Citylrown
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
0"
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc):
Distribution box was video inspected and found in good condition with no rot.Water level was even
with outlet invert.
t5insp.doc•rev.7261=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (front unit)
Property Address
Roger Wharton —
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every State Zip Code Date of Inspection
page. Cityfrown
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order. ❑ Yes ❑ No"
Alarms in working order. ❑ Yes ❑ No`
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
"If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
1
® leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
innovative/alternative system
Type/name of technology:
tsinsp.doc•rev.7/2812018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (front unit)
Property Address
Roger Wharton --
Owner Owner's Name
information is Ma 02601 4/30/2021
required for every Hyannis
page.
Citylrown 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 pit was found 75%full at time of inspection and no stain lines higher.
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.):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
t5msp.doc.rev.7126=8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (front unit)
Property Address
Roger Wharton
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every
page Cityrrown 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.):
t5imp.doc•rev.7/26/2018
Title 5 Official Inspection Form:subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (front unit
Property Address
Roger Wharton
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every State Zip Code Date of Inspection
page. City/Town
D. System Information (coot.)
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
® a
I 2_ 3
0
z 1 I
OZ, )3
(�3 `z9
A3 1�
13Y 22
cl 3/
t5insp.doc•rev.726120'18 Tdle s official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 16
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road(front unit)
Property Address
Roger Wharton
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every state Zip Code Date of Inspection
page. Citylrown
D. System Information (cunt.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
12'+
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 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:
Groundwater was established by accessing town of Barnstable groundwater contour maps.
Before filing this Inspection Report;please see Report Completeness Checklist on next page.
t5insp.doc•rev.71TAM18 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 17 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
r 44 Tevyaw Road (front unit)
Property Address
Roger Wharton
owner Owner's Name
information is Hyannis Ma 02601 4/30l2021
required for every State Zip Code Date of Inspection
page-
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector information: Complete all fields in this section.
® B_ Certification: Signed&Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1,2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8:TightlHolding 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.7126=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
a l�g..aao
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road { rear unit)
Property Address
Roger Wharton
Owner Owner's Name
information is required for every Hyannis ✓ Ma 02601 4/30/2021
page. Cityfrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information 51 j 35 .
on the computer,
use only the tab Sean M.Jones
key to move your Name of Inspector
cursor-do not S.M.Jones Title V Septic Inspection _
use the return Company Name
key.
Company
A Lane Co _
� Company Address
Centerville Ma 02632 _
CitylTown State Zip Code
774-248-4850 smjonestitle5@gmail.com, SI4522
sean@smjonestitle5.com License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
4/30/2021
Inspector's Signature Date
The system inspe o`rshall 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.
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 or 18
Commonwealth of Massachusetts
� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road ( rear unit) _
Property Address
Roger Wharton
Owner Owner's Name
information is H annis Ma 02601 4/30/2021
required for every � .._ __
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:
The property located at 44 Tevyaw Rd Hyannis rear house is served by a Title V septic system
consisting of a 1000 gallon septic tank, distribution box and a 1000 gallon leach pit.Although the
system was found to be in proper working condition at the time of inspection this report does not
guarantee future performance under similar or increased usage.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
l5insp.doc•rev.7/26/2018 Title 5 official Inspection Foam:Subsurface Sewage Disposal System-Page 2 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
V 44 Tevyaw Road (rear unit)
Property Address
Roger Wharton _
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every y _.
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont_)
2) System Conditionally Passes(cost.):
❑ 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18
c Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (rear unit)
Property Address
Roger Wharton _
Owner Owner's Name
information is required for every Hyannis Ma 02601 4/30/2021
page. Citylrown State Zip Code Date of Inspection
C. Inspection Summary (cunt.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** DEP certified laboratory, for fecal
This system asses if the well water analysis, performed at a ry,
Y P Y
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
' El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 official Inspection form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
F Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
44 Tevyaw Road (rear unit)
Property Address
Roger Wharton
Owner Owner's Name
information is required for every Hyannis Ma 02601 4/30/2021
page. Citylrown 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 Y2 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
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 5 of 18
e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road ( rear unit)
Property Address
Roger Wharton _
Owner Owner's Name
information is required for every Hyannis Ma 02601 4/30/2021
page. Citylrown 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 answered"yes"to an question in Section CA above the large system has failed.The
, r o a y any g y
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
M ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15..302(5)]
t5insp.doc-rev.712612DI8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road { rear unit)
" y Property Address
Roger Wharton __
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms(actual): 1
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 9rpd
Description:
2
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Dispcsal System-Page 7 of 18
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road { rear unit)
Property Address �-
Roger Wharton
Owner Owner's Nance
information is required for every Hyannis Ma 02601 4/30/2021
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): -
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to: -
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Tank pumped for inspection
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? size of tank
Reason for pumping: routine maintenance.
t5msp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (rear unit) _
Property Address
Roger Wharton
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)-(if yes, attach previous inspection records, if any)
❑ Innovative/Altemative 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:
system installed 1995 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
1.5
Depth below grade: feet
Material of construction:
❑cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet --
Comments(on condition of joints,venting,evidence of leakage, etc.):
Joints in good condition, no leakage, vented through roof.
I
t5insp.doc-rev.7 MOI8 Title 5 official Inspection Form:subsurface Sewage D'sposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
I
44 Tevyaw Road (rear unit
Property Address
Roger Wharton
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every �----- State Zip Code Date of Inspection
page. Cityrrown
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1 '
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
1000 gallons
Dimensions:
5"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
3'
2"
Scum thickness
7„
Distance from top of scum to top of outlet tee or baffle
10'r _
Distance from bottom of scum to bottom of outlet tee or baffle —
Opened covers and took
How were dimensions determined? _measurements
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
Tank was pumped for inspection and should be done again every 2 years for proper maintenance.
Water level was even with outlet, tank was structurally sound and not leaking.
t5insp.doc•rev.7/2612018 Title 5 Official Inspection form:Subsurface Sewage disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road ( rear unit)
Property Address
Roger Wharton
Owner Owner's Name
information is Hyannis Ma 02601 4/30/2021
required for every y --
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: 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
f Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road ( rear unit)
Property Address
Roger Wharton -
Owner Owners Name
information is Hyannis Ma 02601 4/30/2021
required for every - State Zip Code Date of Inspection
page. ditylrown
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on site plan):
0"
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Distribution box was video inspected and found in good condition with no rot. Water level was even
with outlet invert.
t5lnsp.doc•rev,71262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 12 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road ( rear unit)
Property Address
Roger Wharton
Owner Owner's Name
information is required for every Hyannis Ma 02601 4/30/2021
- ---
page. City/town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type.
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: --�
t5insp.doc•rev.712612018 rdle 5 official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
cam, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road ( rear unit)
Property Address
Roger Wharton _
Owner Owner's Name
information is required for every Hyannis.._ Ma 02601 4/3012021
page. City/Town State Zip Code Data of Inspection
D. System Information (cont.)
11. Soil Absorption System(SA3) (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil,condition of
vegetation, etc.):
Leach pit was found 50%full at time of inspection and no stain lines higher.
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.):
l5insp.doc•rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road ( rear unit)
Property Address
Roger Wharton
Owner Owner's Name
information is required for every Hyannis Ma 02601 4/30/2021
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.):
a
i
t5insp.doc•rev.7l26/2018 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (rear unit).
Property Address
Roger Wharton
Owner Owner's Name
information is required for every Hyannis Ma 02601 4/30/2021
.
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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
AZ
G�
Al 23
6 y sz
t5insp.doc-rev,7/26I2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (rear unit)
Property Address
Roger Wharton _
Owner Owner's Name
information is required for every Hyannis Ma 02601 4/30/2021
page. City/Town state Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 124
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: pate
❑ 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:
Groundwater was established by accessing town of Barnstable groundwater contour maps.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/28/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
44 Tevyaw Road (rear unit)
Property Address
Roger Wharton
Owner Owner's Name
information is required for every H annis _ _ Ma 02601 4/30/2021
y
page. Citylrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed&Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1,2, 3, or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
® D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7J26=18 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
Commonwealth of Massachusetts
w� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-REAR
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
—
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:When filling out A. General Information
forms on the
computer, use 1. Inspector:
only the tab key
to move your Carmen E Shay
cursor-do not Name of Inspector
use the return
key. Shay Environmental Services, Inc.
" Company Name
185 Ashumet Road
Company Address
Mashpee MA 02649
Own City/Town State Zip Code
508-539-7966 3080
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: r__-1 P--•:
® Passes ❑ Conditionally Passes ❑ FAIS -n -i
❑ Needs Further Evaluation by the Local Approving Authority �-=-` --
C7 ti%
1/18/09 cA "
c>^_
Inspector's Ignature Date �
The system inspector shall submit a copy of this inspection report to the Approvi g Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a hared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
LI09
44 Tevyaw Road,Hyannis-Rear•03/08 Title 5 Official Inspection Form_Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
R� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M_
ate.
44 TEVYAW ROAD-REAR
Property Address
Janet Kitfield
Owner Owner's Name
information is
required for y
H annis MA 02601 1/18/09
—
every page. City/Town State Zip Code Date of Inspection
B. Certification (Cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
leach pit has 3.5' Liquid., 4' stain line noted.
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.
Answer yes, no or not determined (Y, N, ND) in the ❑ 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.
ND Explain:
❑ 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
❑ obstruction is removed
44 Tevyaw Road,Hyannis-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-REAR
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
_
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ 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
❑ obstruction is removed
ND Explain:
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
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.
44 Tevyaw Road,Hyannis-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
I
Commonwealth of Massachusetts
_ w6 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
aV 44 TEVYAW ROAD-REAR
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
_
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 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
El ® 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
❑ ® 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.
44 Tevyaw Road,Hyannis-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-REAR
Property Address
Janet Kitfield
Owner Owner's Name
information is required for —y H annis MA 02601 1/18/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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.
44 Tevyaw Road,Hyannis-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-REAR
Property Address
Janet Kitfield
Owner Owner's Name
information is y required for —Hyannis MA 02601 1/18/09
every 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)]
44 Tevyaw Road,Hyannis-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
asye`'°p J 44 TEVYAW ROAD-REAR
Property Address
Janet Kitfield
Owner Owner's Name
information is y required for —H annis MA 02601 1/18/09
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 330 GPD Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: None
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ® Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 9-08
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:
Last date of occupancy/use: Date
Other(describe):
44 Tevyaw Road,Hyannis-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-REAR
Property Address.,
Janet Kitfield
Owner Owner's Name
information is y required for _H annis MA 02601 1/18/09
every page. City/Town State Zip Code Date of Inspection
D. Information S s em y t (cont.)
General Information
Pumping Records:
Source of information:
Board of Health
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):
Approximate age of all components, date installed (if known) and source of information:
1995-BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
44 Tevyaw Road,Hyannis-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
S Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-REAR _
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
-
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2.5
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.):
No evidence of leaks, plumbing properly vented
Septic Tank (locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other (explain)
1,00 gallon tank
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions:
5' x8' x5'
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle 29
Scum thickness 1
Distance from top of scum to top of outlet tee or baffle 4
Distance from bottom of scum to bottom of outlet tee or baffle 13"
How were dimensions determined?
Measured
44 Tevyaw Road,Hyannis-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
�a Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� 44 TEVYAW ROAD-REAR
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
—
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
inlet and outlet baffles in good condition - no evidence of exfiltration or infiltation
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.):
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):
44 Tevyaw Road,Hyannis-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
z I= Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a 44 TEVYAW ROAD-REAR
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
-
every page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert D-Box Present
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.):
one outlet to pit-in fair condition-no cracks or leaks noted
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
I
44 Tevyaw Road,Hyannis-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
yar Title 5 Official Inspection Form
=r� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�� ra 44 TEVYAW ROAD REAR
Property Address
Janet Kitfield
Owner Owner's Name
Information is required for Hyannis MA 02601 1/18/09
—
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits numberE'diam x 6' D
❑ 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.):
SAS fuctioning properly, no liquid in leach pit. 1' effective depth available. Cover is 4" below grade.
Riser installed.
44 Tevyaw Road,Hyannis-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
ay 44 TEVYAW ROAD-REAR
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
-
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
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.):
44 Tevyaw Road,Hyannis-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15.
• � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
/ t 44 TEVYAW ROAD-REAR
Property Address
Janet Kitfield
Owner Owner's Name
information is
required for Hyannis__ MA 02601 1/18/09
every page. City/Town State Zip Code Date of Inspect on
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch 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.
ILL—)
12
Asa I
44 Tevyaw Road,Hyannis-Rear•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
j Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e 44 TEVYAW ROAD-REAR
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 14 feet
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:
Inspector has performed engineering design and perc test on this street.
44 Tevyaw Road,Hyannis-Rear•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
i
LN, Commonwealth of Massachusetts
M Title 5 Official Inspection Form
I? Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is y required for —H annis MA 02601 1/18/09
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:When filling out A. General Information
forms the �I 4 �..l�i J3
computeto r, use 1. Inspector:
only the tab key w
to move your Carmen E Shay
cursor-do not
use the return Name of Inspector _
key. Shay Environmental Services, Inc. 1
Company Name
Q 185 Ashumet Road
Company Address
Mashpee MA 02649
erum City/Town State Zip Code
508-539-7966 3080
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: ' -
I ;
® Passes f❑ Conditionally Passes ❑ Falls
Needs Further Evaluation by the Local Approving Authority4App
N1/18/09Inspector's gnature DateThe system inspector shall submit a copy of this inspection report tog Authority(Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
***`This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Lbtiosal Sy 2/ ��
44 Tevyaw Road,Hyannis•03/08 Title 5 Official Inspection Form'Subsurface Sewage Dstem•Page 1 of 15
Commonwealth of Massachusetts
_ W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�apY 44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
_
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
leach pit has No Liquid., 4' stain line noted.
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.
Answer yes, no or not determined (Y, N, ND) in the ❑ 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.
ND Explain:
❑ 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
❑ obstruction is removed
44 Tevyaw Road,Hyannis•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
every page. City/Town State Zip Code Date of Inspection
B. Certification (Cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ 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
❑ obstruction is removed
ND Explain:
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
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.
44 Tevyaw Road,Hyannis•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e'p 44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is H annis MA 02601 1/18/09
required for _y
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ 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 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
❑ ® 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.
44 Tevyaw Road,Hyannis•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
-
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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.
44 Tevyaw Road,Hyannis.03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 5 of 15
commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
"z 44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
-
every 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
0 ❑ . 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)]
44 Tevyaw Road,Hyannis•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
p 44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
-
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 330 GPD Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x# of bedrooms): 330
Number of current residents: None
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? Z Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 9-08
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:
Last date of occupancy/use: Date
Other (describe):
44 Tevyaw Road,Hyannis•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is required for H annis MA 02601 1/18/09
_y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Board of Health
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):
Approximate age of all components, date installed (if known) and source of information:
1995-BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
44 Tevyaw Road,Hyannis•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
-
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2.5
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.):
No evidence of leaks, plumbing properly vented
Septic Tank (locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,00 gallon tank
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
------------—-—---------------------------------------------------------------------------------------------------------
Dimensions: 5' x 8' x 5'
Sludge depth: 2
Distance from top of sludge to bottom of outlet tee or baffle 29
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle None
Distance from bottom of scum to bottom of outlet tee or baffle None
How were dimensions determined?
Measured
44 Tevyaw Road,Hyannis•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
-
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
inlet and outlet baffles in good condition - no evidence of exfiltration or infiltation
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.):
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):
44 Tevyaw Road,Hyannis•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
ep 44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
_
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert D-Box Present
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.):
one outlet to pit-in fair condition-no cracks or leaks noted
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
44 Tevyaw Road,Hyannis•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
_
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 6'diam x 6' D
❑ 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.):
SAS fuctioning properly, no liquid in leach pit. 1' effective depth available. Cover is 3' below grade.
44 Tev aw Road Hyannis•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Y Y P 9 P Y 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
-
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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.):
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.):
44 Tevyaw Road,Hyannis•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
< � Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is required for y H annis MA 02601 1/18/09
-----------------------------
every page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Sketch Of Sewage Disposal System: Provide a sketch 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.
v
6 -Tj 0 I.S 1 �-
c
44 Tevyaw Road,Hyannis•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
e
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
44 TEVYAW ROAD-FRONT
Property Address
Janet Kitfield
Owner Owner's Name
information is required for Hyannis MA 02601 1/18/09
_
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 14 feet
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:
R. Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Inspector has performed engineering design and perc test on this street.
44 Tevyaw Road,Hyannis•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
TOWN OF BARNSTABLE
LOCATION 7e V y,4 &U SEWAGE # 5"eC
VILLAGE H y A or dI/ S' ASSESSOR'S MAP 6z LOT E/�*-
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY /p ®6
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS l PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER ,/� � r` �: �
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: ✓� �` ��^ +
VARIANCE GRANTED: Yes No
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" TOWN OF BARNSTABLE Q
LOCATION 4 CtLJ — SEWAGE# D,
VILLAGE' ASSESSOR'S MAP&PARCEL PLOZ O v?.0
INSTALLERS NAME&PHONE NO. M G C,,bQr-
SEPTIC TANK CAPACITY I , bW �Q1
LEACHING FACILITY.(type) Y� (size)
NO.OF BEDROOMS 11 ,
OWNER 0C\,QT
PERMIT DATE: 4 �ce -�J5 COMPLIANCE DATE: � �Z
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist m'
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility f. v )4- Feet
FURNISHED BY tl 1
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a
efi
w cz
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14- a
No....•••-.......-....... Fas..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiou for Diopooul Wor1w Tow3trur$ion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal
System at:
.•.••.•:•-••-•••-44A Tevvaw Road Hyannis
•---------------------------------------------------------------•--------------•-•-•--••••....---
Location-Address or Lot No.
................... anet---Kj tfiald--•---------------•-•-•-....------------ -----•-----.......---•-----•---••--•-•-•-•••••---•--••......•---••••-••---•----•-•-•...........••.
owner Address
W ,J-.-P.Ra.CQmhex---Jr.....................................
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwellin X- No. of Bedrooms.............a Expansion Attic Garbage Grinder
( )
aOther—Type
of Building ---------------------------- No. of persons............................ Showers ( ) — Cafeteria ( )
44 Other fixtures ---------------------------------------------------------------------------------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity------------gallons Length_--__.------_-- Width---------------- Diameter---------------- Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area.........._.........sq. ft.
Seepage Pit No..................... Diameter--.-.-------- ...... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
Test Pit No. L---------------minutes per inch Depth of Test Pit.-_--_--._.___--.___ Depth to ground water........................
(X, Test Pit No. 2................minutes per, inch Depth of Test Pit.................... Depth to ground water........................
a --------•-------------------------------•-......--------•------•-•--------------•--•---•----•-...--•.............................-..........................
0 Description of Soil........................................................................................................................................................................
Sand. &._ r v .l...•-•--•----•••--------------------•-•--------•-----------••-----•••......----------•----•--.........................-•-•--•--•-••---••--------
v -
W
---- - - ------ ---
UNature of Reppairs or Alterations—Answer when applicable.-.__Omit.._.c.essPoo 1____Inata_1.1...1,10.0.0.........
-----------------gallon tank, 1---distrbuQ ..bo ---ar1d---- --1-0-0-a...gallon..lsah--Pit................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has be i sued by the b rd f health.
Signed -----312 8.%9 5--------
Dace
Application.Approved By .... ....... o 9------- -- .
Application Disapproved for the following rearons- ..
-11
--------------
----------------------------
---
-- - �D
Permit -------------------- -----Issued � - ! IV
0
� 8
No....... Fxa..Y....?.n.�. W...
THE COMMONWEALTH OF MASSACHUSETTS
4k4OARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Diti-paiial 3Unrkg ( owitrnrtion ramit
.. Application is hereby made for a Permii to Construct ( ) or Repair (XX) an Individual Sewage Disposal
System at:
. 44A Tevyaw Road Hyannia
----------------------------------------------•-------------------•-------•------......••••....---
Location-Address or Lot No.
........................................ ....•-----------------------------------------------•---------------•.............................
owner Address
a ........................ A M C mhf'. FTC------------------------------------ ---------•-----------•----------------------------•-•-•-•-••--•-•--•-••--•-----•--•-............_.
Installer Address
. Type of Building Size Lot............................Sq. feet
Dwelling,No. of Bedrooms-------------I------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ---------------------------- No. of persons.;.......................... Showers ( ) — Cafeteria ( )
04
d Other fixtures _------------------- ------------------=...........................................................................................................
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacitv............gallons Length---------------- Width---------------- Diameter.--------------- Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length-------------------- Total leaching area....................sq. ft.
Seepage Pit No-_------------------ Diameter.....--............. Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date........................................
W
a Test Pit No. 1------_--------minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
G� ----------------------------------------------------------------•------------------•-------------.--.........................................................
0 Description of Soil.......................................................................................................................................................................
xSand &...Gravel..................................................................................................................................................
U
W
UNature of Re airs or Alterations—Answer when applicable_-.Omit---Cesspool., Tn:S. . -�.1... ......_..
ga�lon.... ank_, 1_-distribut-ion box.-and.. 1_-1 OflO,_.aallon---leaG- --- A...............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has be n/ sued by the b and Of health.
Signed ..... ...L. ------------------�4--- ------- ----- -----3/28/9.`5--------
,Q� / Dare
Application.Approved By ... . ( P---- ------:-- -----
Dae
Application Disapproved for the following reasons. .- ------_--------------------------------------------------------------------------------- --------------........._.
......... ..... ......._......_. .. ...... --------- -------------------------- ---------------- ----- ---- ------
Permit No. Issued ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Cle>rtifi a e of C11omplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX�,
- .. " - -
lnsciner
at ... 44A Tevyaw...Road Hyannis
---------------------- ------------- ---------------------------- ----
has been installed in accordance with the provisions of TITLE 5 The tate Environmental Code as described in
the application for Disposal Works Construction Permit No. .. .--------- .. _ dated
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT/BE CON RUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE . ......... ----------------------- ---------- ------------ - Inspecto -- %2� "
�/^ —0ao THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
No ....
....t--------------------
FEE ... i!.e.Sl.l7.
Uispviial Workii Tunotrurtion "amit
Permission is hereby granted..-kT.P.-M a c_rm'f?P!=-• o-----------------------------•--------------------------------------------•---•--••••--•......
to Construct ( ) or Repair-KZ(X) an Individual Sewage Disposal System
at No......44 A... evyaw Road...Hyp n:- s-----------------------
------------------------------------
Street �
as shown on the application or Di posal Works Construct' I�Permit Noated!- -----.
.. �n.
ai of Health --
DATE----------------------� �/� • --- --...r --------_-- -•-------
B
V
FORM 36508 HOBBS 6 WARREN,INC.,PUBLISHERS
i
TOWN OF BARNSTABLE
LOCATION L/e y� �/ SEWAGE # 7A,7 B
VILLAGE nnj 5 ASSESSOR'S MAP & LOT��
INSTALLER'S NAME & PHONE NO. T 1 �"� �h'►�e`' 50A-7ylC;.
SEPTIC TANK CAPACITY 1t900
LEACHING FACILITY:(type) 4— (size) kQQQ
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
R-B OR OWNER
DATE PERMITISSUED:
DATE COMPLIANCE ISSUED: ��
VARIANCE GRANTED: Yes No
�r
.J
TOWN OF BARNSTABLE' V
LOCATION SEWAGE# 9s"�b3
VILLAGE ASSESSOR'S MAP&PARCEL �);W
INSTALLERS NAME&PHONE NO. MGCc9Y1)aQ�
SEPTIC TANK CAPACITY OCR Cam` _
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS ;� 1
OWNER
PERMIT DATE: 3 '1210,- 9,5 COMPLIANCE DATE: cJ�
Separation Distance Between the: f
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching.Facility(If any wetlands exist
within 300 feet of leaching fac' ' ) C(' Feet
FURNISHED BY C�fl��1 vV
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ASSESSORS MAP NO-
No.... � PARCEL NO: 4 a'� FH$$....3�... 0......
THE COMMONWEALTH'OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Appliration for Biin.pnial Work.6 C omitrurtion Urrmit
Application is hereby made for a Permit to Construct ( ) or Repair AX ) an Individual Sewage Disposal
System at: '
44 Tevyaw Road Hyannis,Mass
....................................... --•--------•---•-•-•--------•-•-•-----•------------------ ----------------------------------------------------------•---•-----------------------------------
Location-Address or Lot No.
......................Janet---Kitf_i_eld.................................... --------------------------------------------------------------------...._.....•-•--.....-----.---
Owner Address
W J.P.Macomber Jr.
Installer Address
UType of Building Size Lot............................Sq. feet
Dwellingy=No. of Bedrooms.--____------------------------------- ----Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons------3-------------------- Showers ( ) — Cafeteria ( )
Q' Other fixtures ------------------------------- -
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter----.__......... Depth-_-_-____-_-----
x Disposal Trench—No. .................... Width___---.--..-.-.__--- Total Length-------------------- Total leaching area-------_............sq. ft.
Seepage Pit No...................... Diameter.................... Depth below inlet.................... Total leaching area...........:......sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by------- ----------- ------------------------------------------------------ Date-------------------------------•-------
a
a Test Pit No. 1................minutes per inch Depth of Test Pit____________________ Depth to ground water.........................
44 Test Pit No. 2................minutes per inch Depth of Test Pit--__-_-.________-__- Depth to ground water........................
P4 .........................................................•-••--•----....._---------..._......------..........................................................
0 Description of Soil........................................................................................................................................................................
v ......................Sand--& a
---Grye_1---------•-•-•-----------------------------------------------•-----------•----•-------------------------------•--------------•----------....--
W
UNature of Repairs or Alterations—Answer when applicable._.Omi-t.._oes.spools...___InstalL...9.--_9-1,;!D.O........
......................gallon...tan1.,.1,.distrib_itian..bnx---and...9__-1-0.0.0...gallon---Leach...p_i t-............
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to-place the
system in operation until a Certificate of Compliance has bee iss ed the bo d f health.
Signed /I 3/2 8/9 5
/ DaV
^�
Application.Approved By ---------------------------------- -- ---- - -_ . ...... .... ................ /-.... --
Application Disapproved for the following reasons: ................................................................... . . ......... .....................
.. ... ...................................................... ......... ......... .........
Q. ,-, g p Dace
Permit No. .........:.9 � ..._62 .................... Issued -------------3 d"!....7�._....------
Date
f� '7 a �
No....----•5---k.o—� b `�-O FEB$....��..Q.O......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
- Applirtttiou for Dhi-p Sal Work,i C omitru.rtion Urrmit
Application is hereby made fora Permit to Construct ( ) or Repair }(X ) an Individual Sewage Disposal
System at: ..
44 Tevyaw Road Hyannis,Mass
....................••-••.............••-•-••---••••---•.....------•--.....•-•-----•---........... -----•---.....---•-•-•----••••....-••.............----•-----•-.......-----•--......--••-----------
Location-Address or Lot No.
...................... ....................................
Owner Address
W J.P.Macomber Jr.
a. ---•--••...--•......----•••••---•......•--•--••••--•---•-•---•--••-•--••••••--•••--•-----•••....-• --•---•-•------------••--••-•••---•--•----•--•--•-•-••-•--•------•----••.........................
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling` K"No. of Bedrooms--------z----------------------------- ---Expansion Attic ( ) Garbage Grinder ( )
a`4 Other—Type of Building No. of persons------ Showers
YP g ---------------------------- P - ( ) — Cafeteria ( )
0 Other fixtures -------------------------------•-------------------------------------•----------------
W Design Flow--------------------------------------------gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacity------------gallons Length----------------- Width---------------- Diameter----..-.--.----- Depth................
x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter-------------------- Depth below inlet---................ Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
W Percolation Test Results Performed by=------------------------------------------------------------------- ----- Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit-------------------- Depth to ground water.-..-..-.-----_--_---...
(s, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water......----------------_.
a •-••---•••••----------------••......-••-•••••.....--------•-•••-••••---•••......-•-•...........--•-•: =------•••-----••------•••--•-••..................---•-
DDescription of Soil-----------------------•-----•-• -•-••- • . • -•-- . • •-----•-•-------------••-------•------- ---•••--•----•-••---••-•-•-••-......--••--•----••..••...
W Sand & Gravel
v ----•-•-•------ ------ ----------------•--•-------•-•--------------•-------•----------•--••--•--------------------------------••------------•--------------------------------------....-••-•-•••.....---
W
Z. ---------------------------------------------------- ------------------------------------------------------------------------- ------------------------------------------------•---•---••........--•-•-
U Nature of Repairs or Alterations=Answer when applicable--Qaut.--COS-s—iao 2lS..__..L11 to l.._.9_-_7. �.�........
--------•------------ 1---1.0-6.0...or-a114aa---leach.--- t..-.......
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Compliance has bee issued by the bo rd f health.
/�� � 3/28/95
Signed =1 ------- -- --------- - ._... -------- _........ ......
Date
Application.Approved By ---- ------------------------------ — --- ---- -- - ---------------------------------------------------- -- fs
f Da, ---/.._.
Application Disapproved for the following reason.t: -----------------------------------------------...-----......----------------------------- ----------------------
--------- -------- --------------------------------------------------------------------- ------- -----------------------------...--
�.y Date
Permit No. / �`S 6........... .. --------- ------------------ Issued ---- --------- ------ ...���
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(Qltrtifirak of Complianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaire&�CXG
by------------ ------J.P..Mac.o-tuber.---Jr -------------------------------------------------- -----------....-----------------------------------------------------_---- ----------
Installer
at - 4-4 -levvaw Road...: ..yann i- -- - - ... - - - -
has been installed in accordance with the provisions of TITLE��jy.of Th State Environmental Code as de cribed in
the application for Disposal Works Construction Permit No. .-...5:_ .... _..__.__. dated 1 ' .......
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTR E AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
.�----------
THE1
DATE...._ � ....., ` Inspe tor..- -___—_ ------- ------_�—_ ----_,�---_,_,--,_-------_.---_ --- --_,— —. --COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE!
No......� .:.t............ 3 FEE..$...30..d0..
Ropma1 Workv Tonotrudivit "andt
Permission is hereby granted......_._.J.r_p.-M.a—comber -Jr.
to Construct or Repair `(X). an Individual Sewage Disposal System
at No.
4 . €'Pvyaw Roa Iiyannis
---------- •....
Street as shown on the application for Disposal Works Construction Permit No. .l...s-dr—d3.............. Dated-----..�..� .................
l r - ---- ... ..........................
oard Hea72h�
DATE...............�-•-----•••----•-••---•••-•--••-•-•-••--•-•--•---••-•--.......
FORM 36508 HOBBS A WARREN.INC..PUBLISHERS