HomeMy WebLinkAbout0059 WAGON LANE - Health 59 WAGON LANE
Hyannis
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
^y sVo e
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
1. Property Information:
59 Wagon Ln.
Property Address
Patricia McHugh
Owner's Name
same
Owner's Address
Hyannis MA 02601
City/Town State Zip Code
Date of Inspection: 8/11/10
Date
2. Inspector:
Matthew L. Childs
Name of Inspector
same
Company Name
4 Orchid Ln.
Company Address
W. Yarmouth MA 02673
City/Town State Zip Code
5lephon Numb a �n
1479
Telephone Number D U
�. REC'D
Certification Statement:
I certify that I have personally inspected the sewage disposal system at this address and that th
information reported below is true, accurate and complete as of the ti d spection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® .Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8/11/10
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 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.
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
IPa e 1 of 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
59 Wagon Ln.
Property Address
Hyannis MA 02601
City/Town State Zip Code
Patricia McHugh 8/11/10
Owner's Name Date of Inspection
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:
passes
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:
N/A
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
59 Wagon Ln.
Property Address
Hyannis MA 02601
City/Town State Zip Code
Patricia McHugh 8/11/10
Owner's Name Date of Inspection
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain:
N/A
❑ 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:
N/A
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
1
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
59 Wagon Ln.
Property Address
Hyannis MA 02601
City/Town State Zip Code
Patricia McHugh 8/11/10
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (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: N/A
**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:
N/A
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
A. Certification (cont.)
59 Wagon Ln
Property Address
Hyannis MA 02601
City/Town State ZipCode
Patricia McHugh 8/11/10
Owner's Name Date of Inspection
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
El ® 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 '/z day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply.or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ Z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ Z 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 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.]
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.
I
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
Commonwealth of Massachusetts
Title 5 official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
A. Certification (cont.)
59 Wagon Ln.
Property Address
Hyannis MA 02601
City/Town State Zip Code
Patricia McHugh 8/11/10
Owner's Name Date of Inspection
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.
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
B. Checklist
59 Wagon Ln.
Property Address
Hyannis MA 02601
City/Town State Zip Code
Patricia McHugh 8/11/10
Owner's Name Date of Inspection
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
® El 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?
® 0 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 CM 15.302(3)(b)]
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information
59 Wagon Ln.
Property Address
Hyannis MA 02601
City/Town State Zip Code
Patricia McHugh 8/11/10
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd.
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d N/A
9 ( y 9 (gpd)):
Sump pump? ❑ Yes No ,
Last date of occupancy: N/ADate
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
'
Design flow(based on 310 CMR 15.203): N/A
Gauons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
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:
N/A
Last date of occupancy/use: N/A
Date
Other(describe): N/A
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
a -
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
59 Wagon Ln.
Property Address
Hyannis MA 02601
City/Town State Zip Code
Patricia McHugh 8/11/10
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: Barnstable treatment plant
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000 gal.
gallons
How was quantity pumped determined? sight on truck
Reason for pumping: maintainance
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1983
Were sewage odors detected when arriving at the site? ❑ Yes ® No
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
59 Wagon Ln.
Property Address
Hyannis MA 02601
City/Town State Zip Code
Patricia McHugh 8/11/10
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
2'
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.):
All in good working order at time of inspection.
Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, Fist age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No
certificate)
Dimensions: 8'x5'x5'outside 1000 gal.
Sludge depth: 4
Distance from top of sludge to bottom of outlet tee or baffle 2.7
Scum thickness .3
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 .91
How were dimensions determined? tape measure at pumping
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
59 Wagon Ln.
Property Address
Hyannis MA 02601
City/Town State Zip Code
Patricia McHugh 8/11/10
Owner's Name Date of Inspection
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 shows no signs of leakage and was pumped as maintainance at time of inspection.
Grease Trap (locate on site plan):
Depth below grade: N/A
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
Dimensions: N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/A
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.):
N/A
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
59 Wagon Ln.
Property Address
Hyannis MA 02601
City/Town State Zip Code
Patricia McHugh 8/11/10
Owner's Name Date of Inspection
Tight or Holding Tank (cont.)
Dimensions: N/A
Capacity: N/A
gallons
Design Flow: N/Agallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A Alarm in working order: ElYes❑ No
Date of last pumping: N/A
Date
Comments (condition of alarm and float switches, etc.):
N/A
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0.0'
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box was replaced at time of inspection.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
` Alarms in working order: ❑ Yes ❑ No
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
' M
C. System Information (cont.)
59 Wagon Ln.
Property Address
Hyannis MA 02601
City/Town State Zip Code
Patricia McHugh 8/11/10
Owner's Name Date of Inspection
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:
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:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
1 6'x6' precast pit with 2'-3' of stone had 1' of water and stain lines at 3'. SAS shows no signs of
hydraulic failure.
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
59 Wagon Ln.
Property Address
Hyannis MA 02601
City/Town State Zip Code
Patricia McHugh 8/11/10
Owner's Name Date of Inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer N/A
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Privy (locate on site plan):
Materials of construction: N/A
Dimensions N/A
Depth of solids N/A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
I
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
C. System Information (cont.)
59 Wagon Ln.
Property Address
Hyannis MA 02601
City/Town State Zip Code
Patricia McHugh 8/11/10
Owner's Name Date of Inspection
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.
/8
,f 59 Y
•
2
A 1-23.5 B-1-25'
A-2-31' M-W
A 3-37 M-36
A4-46' B4433
. l
mchugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
59 Wagon Ln.
Property Address
Hyannis MA 02601
City/Town State Zip Code
Patricia McHugh' 8/11/10
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
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:
Barnstable GIS
You must describe how you established the high ground water elevation:
Barnstable GIS, approx. 55' to groundwater.
Lm�c'hugh.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
No. g®t,V —3qy Fee
t THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
�e 0[pplication for DigpOgal *p5tem COn5trUCtion Permit
Application for a Permit to Construct(iRepair( ) Upgrade( ) Abandon( ) ❑ Complete System Vindividual Components
Location Address or Lot No. � ® .� Ow is Name,Address,and Tel.No.
Assessor's Map/Parcel
Installer, Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
L �&
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided n gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by th' Board of Health.
Signed r Date
Application Approved by ` Date o
Application Disapproved by: Date
for the following reasons Permit No. g-010 / Date Issued ^��
No. 0010 Fee V(/
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
£" y� 01ppi cation for Mioogal iip!5tem Confstructio'n Permit
Application for a Permit to Construct Repair( ) Upgrade( ) Abandon( ) ❑ Complete System W Individual Components
7
Location Address or Lot No. m A OPhi
's Name,Address,and Tel.No.
70 19(3 Y
Y
t jAssessor's Map/Parcel y}-;-`j r(� d C v
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
j Eklq-,) 1�sL`I
� 4 a 2t v
Type of Building:
1)wellin No.of Bedrooms Lot Size s . ft. Garbage Grinder
g q g ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided_ gpd
j
Plan Date Number of sheets Revision.Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
I
i
Nature of Repairs or Alterations(Answer when applicable)
i
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in''>
accordance �+o dance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of ;.
' Compliance has been issued by this Board of Health.
v
I Signed Date ^"
-�-
j Application Approved by � Date (p '
i
j Application Disapproved by: Date
r for the following reasons
Permit No. goto — 3 q Date Issued ^to
THE COMMONWEALTH OF MASSACHUSETTS
4 Or BARNSTABLE, MASSACHUSETTS
V (Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired ( ) Upgraded ( )
Abandoned( )b
at has been constructed in accordance q /�
with'the provisions of Titl 5 and the for Disposal System Construction Permit No a01�' 7`t y dated 9^
Installer Designer
#bedrooms Approved design flolyl , gpd
The issuance of this Perqt shall not be construed as a guarantee that the system w 1 fu cho as desig e
Date p � Inspector
t �S
_
---—.—N o '- �.�(,�
I,d �, �_——,..�_�.-� Fee
THE COMMONWEALTH OF MASSACHUSETTS `
PUBLIC HEALTH DIVISION — BARNSTABLE MASSACHUSETTS
nigpoal *p!5tem Congtruction permit
Permission is hereby granted to Construct ( ) epair ( ) Upgrade ( ) Abandon ( )
System located at
tIII-In
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this pe
(v Date Approved by
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�., 59 WAGON LN
Property Address
PATRICIA`MCHUGH
Owner Owner's Name
information is HYANNIS MA 02601 10/10/07
required for State Zip Code Date of Inspection
every page. City/Town
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important: A. General Information �1
When filling out tl
forms on the
computer,use 1. Inspector:
only the tab key
to move your- Michael DeDecko lfL
cursor-do not Name of Inspector
use the return
key. Compass Realty Development Corporation
Company Name
rab P.O. Box 2384
Company Address
Mashpee Ma 02649
rPnon City(rown State Zip Code
508-221-5003
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection: The.inspection
was performed based on my training and experience in the proper function and!maintenance of.on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system: ' }
® Passes ❑ Conditionally Passes El ails
❑ Needs Further Evaluation by the Local Approving Authority
10/10/07
Ains�ptc-tors 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 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.
342 LAKESHORE DR•08/06 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 59 WAGON LN
Property Address
PATRICIA MCHUGH
Owner Owner's Name
information is HYANNIS MA 02601 10/10/07
required for State Zip Code Date of Inspection
every page. City/Town
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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.
R
*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
342 LAKESHORE DR•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 59 WAGON LN
Property Address
PATRICIA MCHUGH
Owner Owner's Name
information is HYANNIS MA 02601 10/10/07
required for
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: g
r.
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
16.303(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.
342 LAKESHORE OR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 WAGON LN
Property Address
PATRICIA MCHUGH
Owner Owner's Name
information is required for HYANNIS MA 02601 10/10/07
every page. Cityfrown 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
El 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.
342 LAKESHORE DR•08/06 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
59 WAGON LN
Property Address
PATRICIA MCHUGH
Owner Owner's Name
information is HYANNIS MA 02601 10/10/07
required for State Zip Code Date of Inspection
every page. City/Town
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.
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.
E) Large Systems: To be considered a large system the system must.serve a facility with ia
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
342 tAKESHORE DR•08/06
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
59 WAGON LN
Property Address
PATRICIA MCHUGH
Owner Owner's Name
information is required for HYANNIS MA 02601 10/10/07
every page. Cityrrown 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
El ® 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?
Z ❑ Were all system components, excluding the SAS, located on site?
t
® ❑ 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
El ® 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)]
342 LAKESHORE DR•08106 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
59 WAGON LN
Property Address
PATRICIA MCHUGH
Owner Owner's Name
information is HYANNIS MA 02601 10/10/07
required for
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual):
3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
0
Number of current residents:
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
N/A
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
N/A
Last date of occupancy: 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):
342 LAKESHORE DR-08/06 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
M 59 WAGON LN
Property Address
PATRICIA MCHUGH
Owner Owner's Name
information is required for HYANNIS MA 02601 10/10/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
F
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 no) (if yes, attach previous inspection records, if any)
El maintenance
technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1983
Were sewage odors detected when arriving at the site? ❑ Yes.❑ No
342 LAKESHORE DR•08I06 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
M
59 WAGON LN
Property Address
PATRICIA MCHUGH
Owner Owner's Name
information is HYANNIS MA 02601 10/10/07
required for
State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.) '
Building Sewer(locate on site plan):
2'
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 TIGHT,YES VENTED,NO LEAKAGE.
Septic Tank (locate on site plan):
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
-=------------------------------------------------------------------------------------------------------------------------
Dimensions: 1000 gal
3"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle
31"
2„
Scum thickness
1001
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
14"
How were dimensions determined? MEASURED
342 LAKESHORE DR-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 WAGON LN -
Property Address
PATRICIA MCHUGH
Owner Owner's Name
information is required for HYANNIS MA 02601 10/10/07
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.):
NEED TO PUMP, TEE'S INTACT,STRUCTALLY SOUND, LIQUID LEVEL EQUAL WITH OUTLET
INVERT, NO LEAKAGE,
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
El 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):
342 LAKESHORE OR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w„ 59 WAGON LN
Property Address
PATRICIA MCHUGH
Owner Owner's Name
information is HYANNIS MA 02601 10/10/07
required for
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 EQUAL WITH 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.):
D BOX IS LEVEL AND DISTRIBUTION EQUAL, YES SOLID CARRYOVER, NO LEAKAGE.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes' ❑ No
Alarms in working order: ❑ Yes ❑ No
342 LAKESHORE DR-08/06 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
�M 59 WAGON LN
Property Address
PATRICIA MCHUGH
Owner Owner's Name
information is required for HYANNIS MA 02601 10/10/07
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: 1/6X6
❑ 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.):
SOIL-GRAVEL/SAND, NO SIGNS OF HYDRAULIC FAILURE, PONDING 3'6",NO DAMP SOIL,
VEGETATION - NORMAL.
r
342 LAKESHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 WAGON LN
Property Address
PATRICIA MCHUGH
Owner Owner's Name
information is HYANNIS MA 02601 10/10/07
required for
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.):
342 LAKESHORE DR-08106 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
^M 59 WAGON LN
Property Address
PATRICIA MCHUGH
Owner Owner's Name
information is HYANNIS MA 02601 10/10/07
required for State Zip Code Date of Inspection
every page. City(Town
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.
t
2.
a 3
Li
z- 3 ► '
tA3
•
342 LAKESHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
59 WAGON LN
Property Address
PATRICIA MCHUGH
Owner Owner's Name
information is HYANNIS MA 02601 . 10/10/07
required for
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 round depth to water: 56'_
p g 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:
BARNSTABLE GIS
You must describe how you established the high ground water elevation:
BARNSTABLE GIS
I
342 LAKESHORE DR•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 15 of 15
Town of Barnstable
' � of the ram,
Regulatory Services
BARNSTABLE ; Thomas F. Geiler,Director
MASS.
1639. ��� Public Health .Division
ArfD��p
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
_ == COMMONWEALTH OF I`LkSSACHtiSETTS
r, EhECL TTVE OFFICE OF E.�'VIRONMEITAL AFFAIFS
DEPARTMENT OF ENVIRONNTAL PROTEC
ME 2
-- ONE R'INTER STREET. BOSTON \LA 02108 (617) 292-i i 111\ 1
a
0, �F�14 UDY COX
T � Secre:ai
l0 �sSTR
ARGEO PAUL CELLUCCI DA B. miss::Y.
Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIO FORM �.y�{� 99
�v� �,C PART A �F'
CERTIFICATION g
Property Address: ll- �o.-� l.-�� f t�'��I`J Name of Owner
i UAW
Address of Owner:
Date of(nspection:.41 Zfj�� �+ / r/1� �/U
Name of Inspector:( lase Prirn)/ ! G_fr a c� �f�CC /"
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: af �a+ �r �k�.'rc•,t, kka C w+u
Iillpiling Address:,---',---) Ant
Telephone Number: ;X. Lo
CERTIFICATION STATEMENT
have personally inspected the sewage disposal s st' em at this address and that the information reported below is true, accurate
I certify that
and complete as of the time of inspection. The inspection wa performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The syster/
Passes
_ Conditionally Passes
_ Needs Further on By t e Local Approving Authority
Fa
i
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEPlwithin thirty (30) days of
completing this inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owne,
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to ttre
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 /ceIof11 -
i
A �� Pnnted enfkcycW Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
"roperty-Address:
Jwner, t
Date of Inspection:
INSPECTIO SU MARY: Check A, B, C, o/ D:
M SYSTEM PASSES:
a
e not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
Xcriteria•hot evaluated are indicated below.
COMMENTS. 3'►Y
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.
Indicate yes, no, or not determined(Y. N. or NO). Describe basis of determination in all instances. If "not determined",explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high.static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced --
_ The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in orde to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCO ANCE WITH 310 CMR 15.303 (1)(b)THAT THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLI HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water .
Cesspool or privy is within 50 feet of a bordering vegetated etland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AN PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUB IC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorpt' n 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 soil absor Lion system and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil abs ption system and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil abs rption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well ater analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that fac'ity and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determin distance (approximation not valid).
31 OTHER
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revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" t .each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure
Yes No
_ Backup of sewage into faci ty or system component due to an overloaded or clogged SAS or cesspool.
_ Discharge or ponding of efflu nt to the surface of the ground or surface waters due to an overloaded or clogged SAS cr
cesspool.
_ Static liquid level in the distribu ion box above outlet invert due to an overloaded or clogged SAS or cesspool.
_ Liquid depth in cesspool is less t n 6" below invert or available volume is less than 1/2 day flow.
_ Required pumping more than 4 tim s in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
_ Any portion of the Soil Absorption S tem. cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is w thin 100 feet of a surface water supply or tributary to a surface water supply
Any portion of a cesspool or privy is wit in a Zone 1 of a public well.
_ Any portion of a cesspool or privy is withr 50 feet of a private water supply well.
_ Any portion of a cesspool or privy is less-th n 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the we I has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compound ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to he criteria above:
The system serves a facility with a design flow of 10,000 g d or greater(Large System) and the system is a significant threat to public
health and safety and the environment because one or more f the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking wa er 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' ellhead Protection Area-IWPA) or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further information.
1
revised 9/2/98 Page 4arU
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART e
CHECKLIST
Property Address: 5
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
'+5(� Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
xAs built plans have been obtained and examined. Note if they are not available with N;A.
> The facility or dwelling was inspected for signs of sewage back-up.
��— The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
X _ All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
e (� Existing information. For example, Plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
(15.302(3)(b)]
The facility owner (and occupants,if different from owner) were provided with information on the proper maintenaoca-0f
Subsurface Disposal Systems.
I
revised 9/2/98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION
'roperty Address: ,
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 5 g.p.d./bedroom.
Number of bedrooms (design): O� Number of bedrooms (actuall:G1,
Total DESIGN flow2T�
Number of current residents:-L—,Z.
Garbage grinder(yes or no): 0 l
Laundry(separate system) ( or no):fJ : If yes, separate inspection required
Laundry system inspected yes r no)
Seasonal use (yes or no):_L_�
Water meter readings, if available (last two year's usage (gpd):
Sump Pump (yes or no):
Last date of occupancy: v�
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow: qPd ( Based on 15.203)
Basis of design flow
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: z
Last date of occupancy: .
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Nib
System pumped as part of inspection: (yes or no)_
If yes, volume pumped: gallons
Reason for pumping:
F 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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed Of known) and source of information:_
Sewage odors detected when arriving at the site: (yes or no)
revised 9/2/95 Page6(if II
• 4r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty AddressS�
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan) �1 1
Depth below grade:_
Material of construction: _cast iron_40 PVC_ other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: rtl
(locate on site p a
�l
Depth below grade:
Material of construction: concrete_metal_Fiberglass _Polyethylene other(explain)
If tank is metal, list age_ Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: Ip60 �fi'�
Sludge depth: �� t 1
Distance from top of4ludge to bottom of outlet tee or baffle:
Scum thickness:_ 0
Distance from top of scum to top of outlet tee or baffle:_ 61
Distance from bottom of scum to bottom of outlet a or baffle:��
How dimensions were determined:
;omments:
(recommendation for pumping, condition of in t a d outlet tees or es, depth of liqui�l level in relation to owlet inve t, structural' tegrity,
evidence leakage,etc.
GREASE TRAP:���
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_Nberglass _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:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
revised 9/2/98 page 7or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or 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
Alarm level: Alarm in working order: Yes _ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: -
(locate on site planl V
Depth of liquid level above outlet invert: 0�29 ,w"�'�
Comments: -
Com(not if s: a d istributi i eq I, a 'den"of solids carrygver, evi ce of leakage into or out of box, etc.)
PUMP CHAMBER
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
s
(note condition of pump chamber, condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 9of1I
�1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address: 5 .C-
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):*•S
(locate on site plan, if possible: excav ion not required.location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments: i.
(note condition of soil, signs of hydraulic f 'ure, level of ponding, damp oil, conditi n of vegetal a
�lJ
CESSPOOLS:
(locate on site lan)
Number and configuration:
Depth-top of liquid to inlet invert:
9epth of solids layer:
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:1
(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.)
revised 9/2/98 Pygc9Of11
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:
)wner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
2-
d
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AZ
A 5I of
revised 9/2/98 Page 10oru
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
ropef y Address:
Owner:
Date of Inspection:
NRCS Report name — --
Soil Type_ — --
Typical depth to groundwater_ _ _
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface waterk3C)
Check Cellar
Shallow wells r
Estimated Depth to Groundwater� DFeet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property. observation hole. basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked.FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how youe stablished the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page tl of II
A
TD�NN OF
VU LAG:.-�� fi — ASSESSOR'S INN p & LOT�LTQ4
LNS T A.LLE.'R'S NAME&PHONE NO.
SUMC TANK CAPACITY _ bDO t _ -----
I.HACHIN; FACILITY: (type) 1�CT— __— ;size) 7�
NO.OF BEDROOMS- 1
BUILDER OR OWNER -----
"DATs:. _COMPLLMNCE DATE:--- -_—__--
Scpa 6or,Distance Between the:
Ma.mmum Adjusted Groundwater Table him
Private Water Supply Well and Leaching Facility (If any wells e.tist
on site or within 200 feet of !,-aching faciLzv)
Edge of Wedand and Leaching Facility (If any wcd.uids c.vsc �
{� E
wit`un 300 feet of!caching frcility
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