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NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: CG d� DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
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SEPTIC TANK CAPACITY jj2oja
LEACHING FACILITY:(type) P ( (1 n size)
NO. OFBEDROOMS PRIVATE WELI;'0 UBLIC W TER
BUILDER OR
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUEDz /
VARIANCE GRANTED: Yes No
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Commonwealth of Massachusetts
f
Title 5 Official Inspection Form
' ,-1*4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
`�' -;,!✓ 9 Uncle Joes Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) 4&
V
Owner Owner's Name
information is
required for every Hyannis MA 02601 3-28-17
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73 +.
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S 13971
Telephone Number License Number
B. Certification
I certify that l have personally inspected the sewage,disposal system at this address and that the
information reported below,is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes 0 ,Conditionally Passes ❑ Fails
_ ❑ Needs Further Evaluation b t e Local Approving Authority
3-29-17
Inspector's Signature Date y ,`
.
71
The system inspector shall submit a copy,of this inspection report to the Approving Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or' , y
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
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Commonwealth of Massachusetts
r+ ,z Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Uncle Joes Way
t J'
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-28-17
•
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Exp'lain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
: f Title 5 Official Inspection Form
l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Uncle Joes Way _._...�
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name •
information is
required for every Hyannis +' MA_ 02601 3-28-17.
page. City/Town' _ State Zip Code Date of Inspection
B. Certification .(cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms,are repaired. '
B) System Conditionally Passes (cont.):
❑ Observation ofsewage•backup or break out or high static water level in the distribution box due
s 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):
El obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C 'Further Evaluation is Required q d by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
` safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
�al Title 5 Official Inspection Form
r
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
'Wf.i J9! 9 Uncle Joes Way
Property Address
Bank Owned (Contact David Holt @ Today Real'Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-28-17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
a=1 ; Title 5 Official, Inspection Form
' ,:-� Subsurface Sewage.Disposal System Form Not for Voluntary Assessments
Uncle Joes Way
Property Address
Bank Owned (Contact David,Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is
required for every Hyannis -r MA 02601 3-28-17
page. City/Town - State Zip Code Date of Inspection
B. Certification (cont.)
Yes - No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
® +Any" portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
s 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
E., ❑ Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Uncle Joes Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-28-17
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
❑ ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220— LL
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
:a=l Title 5 Official Inspection Form
f�1
Subsurface Sewage,Disposal,System Form Not for Voluntary Assessments
9 Uncle Joes Way
Property Address — ;,.
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448) _
Owner Owner's Name
information is required for every Hyannis MA 02601 3-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:,* 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection, Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Unknown
Date
Commercial/Industrial Flow Conditions:.
Type of Establishment: -
Design flow(based on 310 CMR 15.203): Gauons per day(gpd)
Basis of,design flow(seats/persons/sq t., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
,Z' Title 5 Official Inspection Form
Y1-1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 Uncle Joes Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: N/A
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 Inc.) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth'of Massachusetts
a=1 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 Uncle Joes Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Hyannis MA 02601 3-28-17
required for every y '
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1980's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan): M
Depth below grade:
16"
feet
Material of construction:
® cast iron "® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
8°
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
12°
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection Form
f
' 1A Subsurface Sewage Disposal System Form Not for Voluntary Assessments
9 Uncle Joes Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-28-17
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: ------ --
Date
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
i
Commonwealth of Massachusetts
R, Title 5 Official Inspection Form
I�I Subsurface Sewage Disposal S stem For -
c-�
gy m .Not for Voluntary Assessments
9 Uncle Joes Way
Property Address
Bank Owned (Contact David.Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: „
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�1�I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
9 Uncle Joes Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from pit.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
,r
Title 5 Official . Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
F
9 Uncle Joes Way
Property Address
Bank Owned (Contact David Holt @ Today.Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) `
F Type. .
® -leaching pits number: 1-1000 gal
❑ leaching chambers number:
f..
❑ i 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.):
Leach pit in good condition and empty at inspection with stain line at 24" below inlet invert..
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet.invert
Depth of solids layer:
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�'�-I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
-', 9 Uncle Joes Way
1-
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
.�"1 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� !� 9 Uncle Joes Way `
Property Address
Bank Owned (Contact David Holt @ Today•Real Estate-1-800-966-2448).
Owner Owner's Name
information is required for every Hyannis MA 02601 3-28-17
page. City/Town State Zip Code Date of Inspection
D. System Information'(cont.)-
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached,separately
d
j
rrrr�wr r ■�.rr�ri r�ier�il�w6s.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
.a=1
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
_ ! 9 Uncle Joes Way
t J
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-28-17
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: 12
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:
USGS and town maps show groundwater at greater than 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
WA Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 Uncle Joes Way
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Hyannis MA 02601 3-28-17
required for every H y y
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
6
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
r
DEPARTMENT OF ENVIRONMENTAL PROTECTION
a
SV�
350 MAIN STREET
WEST YARMOUTH,MA
508-775-2800
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART RECEIVED
CERTIFICATION
MAP 292 PAR 082001 MAY 1
Property Address: 9 UNCLE JOE'S WAY 2002
HYANNIS,MA 02601
ABLE
Owner's Name: ROGER NELSON TOWN OF BAR
HEALTH DE
TPT..
Owner's Address: 276 CENTRAL STREET
SAUGUS,MA 01906
Date of Inspection APRIL 11,2002 4, 9
Name of Inspector:(please print) JAMES D.SEARS MAP 2- 1
Company Name: A&B Canco
Mailing Address: 350 Main Street PARCEL
West Yarmouth,MA 02673
Telephone Number: 508-775-2800 LOT
CERTIFICATION STATEMENT
I certify,that I have personally inspected the sewage disposal system at this address and that the information
reported below is true,accurate and complete as of the time of 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:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of
Health or DEP)within 30 days of completing this inspection. If the system 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 ,+F-
appropriate regional office of the DEP.'The original should be sent to the system owner and copies sent tot
he buyer,if applicable,and the approving authority.
Notes and Comments
PROPERTY IS ALSO LISTED AS 398 FALMOUTH ROAD
****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.
Title 5 Inspection Form 6/15/2000 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 9 UNCLE JOE'S WAY
HYANNIS,MA 02601
Owner: NELSON,ROGER
Date of Inspection: APRIL 11,2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: X
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
_ 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 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
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:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 9 UNCLE JOE'S WAY
HYANNIS,MA 02601
Owner: NELSON,ROGER
Date of Inspection: APRIL 11,2002
C. Further Evaluation is Required by the Board of Health: N/A
_ 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 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 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 9 UNCLE JOE'S WAY
HYANNIS,MA 02601
Owner: NELSON,ROGER
Date of Inspection: APRIL 11,2002
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded .
or clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in pit is less than 6"below invert or available volume is less than day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)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: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 9 UNCLE JOE'S WAY
HYANNIS,MA 02601
Owner: NELSON,ROGER
Date of Inspection: APRIL 11,2002
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
N/A Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X 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
X Was the facility owner(and occupants if different from owner)provided with information on the
proper maintenance of subsurface sewage disposal systems?
stems?P g P Y
The size and location of the Soil Absorption System(SAS)has been determined based on:
Yes No
X Existing information. For example,a plan at the Board of Health.
X 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(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 9 UNCLE JOE'S WAY
HYANNIS,MA 02601
Owner: NELSON,ROGER
Date of Inspection: APRIL 11,2002
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 4-01 465 CU.FF./4-02 518 CU.FT.
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
C OM M ERC IA LANDUS TRIA L
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: AUGUST 1995
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X 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)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
AUGUST 1992
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 UNCLE JOE'S WAY
HYANNIS,MA 02601
Owner: NELSON,ROGER
Date of Inspection: APRIL 11,2002
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): X
Depth below grade: 101,
Material of construction: X concrete metal fiberglass polyethylene
_ other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 12"
Distance from top of sludge to the bottom of outlet tee or baffle: 181,
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 11"
Distance from bottom of scum to bottom of outlet tee or baffle: 17"
How were dimensions determined: TAPE AND SLUDGE STICK
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
TANK AT WORKING LEVEL.TANK AND COVERS 10"BELOW GRADE.ONE INLET TEE,OUTLET BAFFLE..
NO SIGN OF OVERLOADING SEEN IN TANK. TANK SHOULD BE PUMPED
GREASE TRAP(located on site plan) N/A
Depth below grade:
Material of construction: concrete metal fiberglass _ polyethylene e other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 UNCLE JOE'S WAY
HYANNIS,MA 02601
Owner: NELSON,ROGER
Date of Inspection: APRIL 11,2002
TIGHT or HOLDING TANK: N/A" (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/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.,):
DISTRIBUTION BOX IS 16"X16",23"BELOW GRADE.ONE LINE IN,ONE LINE OUT.BOX IS CLEAN AND
SOLID.NO SIGN OF OVERLOADING OR SOLID CARRY OVER.
PUMP CHAMBER: N/A (locate on site plan)
working in Pumps es or no):
g order(Y
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11 '
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 UNCLE JOE'S WAY
HYANNIS,MA 02601
Owner: NELSON,ROGER ..
Date of Inspection: APRIL 11,2002
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X 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:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.)
` LEACHING IS ONE 1,000 GALLON PRE CAST PIT.PIT AND COVER ARE 18"BELOW GRADE. Y WATER
I NO HIGH STAIN LINE.NO SIGN OF OVERLOADING SEEN IN PIT.
CESSPOOLS: N/A (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:
n water.inflow es or no :
Indication of grou d (y )
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 9 UNCLE JOE'S WAY
HYANNIS,MA 02601
Owner: NELSON,ROGER
Date of Inspection: APRIL 11,2002
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.
b
o
Title 5 Inspection Form 6/15/2000 10
Page 11 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
.. PART C
SYSTEM INFORMATION(continued)
Property Address: 9 UNCLE JOE'S WAY
HYANNIS,MA 02601
Owner: NELSON,ROGER
Date of Inspection: APRIL 11,2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater_ 26 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
X Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS WELL DATA
WELL AIW 230 26'
ZONE D 7.5
ADJUSTED 18.5
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Title 5 Inspection Form 6/15/2000 1 1