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-Y TOWN OF BARNSTABLE
LOCATION l�12 f— SEWAGE #
7
VILLAGE ASSES S MAP & LOT
,J46,
� ' ,,:NAME&PHONE N . v
SEPTIC TANK CAPACITY /0 /,// G
LEACHING FACILITY: (type) �/ (size)
NO.OF BEDROOMS
BUILD ER 0 OWNER
PERMUDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 o ac g fac lity) Feet
Furnished by ! �
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Commonwealth of Massachusetts av (a �I�
:a=1 z Title 5 Official- Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
68 Wagon Ln
Property Address Ptia
Qadir Bakhsh
Owner Owner's Name
information is V
required for every Hyannis ✓ MA 02601 8-11-16 � i
page. City/Town State Zip Code Date of Inspection 1•3 N
Ihd
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please seeL 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 S13971
Telephone Number License Number
B. Certification
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:
Z Passes ❑ Conditionally Passes ❑ Fails.
❑ Needs Further E . luation by.the Local Approving.Authority
8-11-16
rhspeotor'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.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
�0y9V�
Commonwealth of Massachusetts
a=1 Title 5 Official Inspection Form
fW
' 11.1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
68 Wagon Ln
F4 Property Address
f1' . Qadir Bakhsh
Owner Owner's Name
information is Hyannis MA 02601 8-,11-16
required:"for every y
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 (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
�al Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
68 Wagon Ln
Property Address
Qadir Bakhsh
Owner Owner's Name
information is required for every Hyannis MA 02601 8-11-16
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 of sewage backup or break out or.high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven,distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N' ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
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
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
h Title 5 Official Inspection Form
', Subsurface Sewage Disposal System Form -Not.for Voluntary Assessments -
68 Wagon Ln
t J'
Property Address
Qadir Bakhsh
Owner Owner's Name
information is required for every Hyannis MA 02601 8-11-16.
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 followinglor all inspections:
Yes No
Backup of sewage into facility component ors stem due to overloaded or
Y
clogged SAS or cesspool'
® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El
® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than day flow
t5ins-3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
f� Title 5 Official Inspection Form
rI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r�
68 Wagon Ln
t J"
Property Address
Qadir Bakhsh
Owner Owner's Name
information is required for every Hyannis MA 02601 8-11-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D. .
Yes No
❑ ❑ the system.is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El Elthe system is located in a nitrogen sensitive area (Interim.Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
:a=1 Title 5 official Inspection Form,,
G,,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,
68 Wagon Ln
Property Address
Qadir Bakhsh
Owner Owner's Name
information is required for every Hyannis MA 02601 8-11-16 "
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.
®r , ❑r Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms,(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6of 17
r
i
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection Form
:�I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a%
;,_�_s}!✓ 68 Wagon Ln
Property Address
Qadir Bakhsh
Owner Owner's Name
information is required for every Hyannis, MA 02601 8-11-16
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage gnnder? ❑ Yes Z No
I Is laundry on a separate sewage system? (Include laundry system inspection f El Yes ® No information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes 2 No
Last date of occupancy: 8-2016
Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design'flow (based on•310 CMR 15.203): Gallons per day(gpd)
I
Basis of.design flow(seats/persons/sq.ft., etc.):
3
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
a f Title 5 Official, Inspection Form
1121, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a/
68 Wagon Ln
Property Address
Qadir Bakhsh
Owner Owner's Name
information is
required for every Hyannis MA 02601 8-11-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) s t
Last date of occupancy/use: Date
Other(describe below):
General Information - -
Pumping Records:
E ,
Source of information: Owner--2015 r
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe)::
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Rill Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
68 Wagon Ln
Property Address
Qadir Bakhsh
Owner Owner's Name
information is required for every Hyannis MA 02601 8-11-16
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:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 12"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):
Depth below grade: 4"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
I
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:
1211,
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
,1� Subsurface Sewage Disposal System.Form -Not for Voluntary Assessments
_s;!✓ 68 Wagon Ln
t J'
Property Address
Qadir Bakhsh
Owner Owner's Name
information is required for every Hyannis MA 02601 8-11-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.) f .-
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness
1"
6"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
15"
Hovel 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.
a
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
:a=1 Title 5 Official Inspection Form
�If,., Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
k.
%
68 Wagon Ln
Property Address
Qadir Bakhsh
Owner Owner's Name
information is required for every Hyannis MA 02601 8-11-16
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 El-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.):
O
*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
n , Title 5 Official Inspection Form
l �r. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
68 Wagon Ln
Property Address
Qadir Bakhsh
Owner Owner's Name
information is required for every Hyannis MA 02601 8-11-16
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 field.
r
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
1a=1 f
Title 5 official Inspection Form
If;., Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
� a
68 Wagon Ln
Property Address
Qadir Bakhsh
Owner Owner's Name
information is required for every y H annis - MA 02601 8-11-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2-500's
❑ 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 chambers in good working order and empty at inspection with stain line at 16" 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection Form
' 4 Subsurface Sewage Disposal System Form -Not,for Voluntary Assessments
� f7
68 Wagon Ln
Property Address
Qadir Bakhsh
Owner Owner's Name
information is required for every Hyannis MA 02601 8-11-16
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
I
Commonwealth of Massachusetts
.a=1
f
Title 5 Official, Inspection. Form
' '�-1 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
a'
68 Wagon Ln
Property Address
Qadir Bakhsh
Owner Owner's Name
information is required for every Hyannis MA 02601 8-11-16
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
No NOW—
T1
t? �
• r .Fr 5(6y,
7 - � �
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts >
Q, Title 5 Official Inspection. Form
l . I Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
68 Wagon Ln
t !'
Property Address
Qadir Bakhsh
Owner Owner's Name
information is required for every Hyannis MA 02601 8-11-16
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:
i
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health - explain:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you'established the high ground water elevation:
Original design plans show no groundwater at 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
r� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
a%
68 Wagon Ln
Property Address
Qadir Bakhsh
Owner Owner's Name
information is required for every Hyannis MA 02601 8-11-16
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNS'TABLE 1/
LOCATION 6�p SEWAGE # -20
VILI;AGE ASSESSOR'S MAP & LOT o4 70 0 6
INSTALLER'S NAME&PHONE NO. `7i'O3 Lc 'Bo�d/� 9 7J-07 07
SEPTIC TANK CAPACITY �X�'r'� moo- �_4'<<•
f. LEACHING FACELI TY: (type) (size)
Nc).OF BEDROOMS -T Keiy-o—y�
BiJILDER OR OWNER 8�6.�i�%1'/Y �'
PERMPTDATE: 9 rs o—o y COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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) i Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
O
0 `
{
v y LL rr led
Na, �T Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _i
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE.. MASSACHUSETTS
2ppItration for Mts;paar Con!Wurtton 30ermtt
Application for a Permit to Construct( )Repair( )Upgrade( Abandon( ) ❑Complete System O Individual Components
Location Address or Lot No. ���0 a./ All o Owner's Name,Address and Tel.No.
Assessor's Map/Parcel�-7O Toe
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
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 gallons per day. Calculated daily flow gallons.
Plan Date 9 � Number of sheets Revision Date
Title
Size of Septic Tank 4get'�I.-7"!n �' ��®�WZ- 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 Certifi-
cate of Compliance has been issue y thi Boazd of Health.
Signed Date/ O
Application Approved by Date
Application Disapproved for the following reasons
Permit No. o-g!e=�+q !:7 Date Issued
+
} � �'"r ^►+•�„s .Y'P' 'fi+``P t-.T v .,h.�r�Fc'n.7.`.'�-..:`.:vw�.C..L1...n.+.�y ..."F"�1' :..v.'rv'... -+.,- -,�'-r. �,,,C.—, v✓.,,.r?-i5-
` Q`Fe,�� ��`� �� •''] � ` �� _ Fee
—+THE COMMONWEALTH OF MASSACHUSETTS Entered in computer-:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
ZLpprication for Migaar *pg em Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade,,,( )Abandon( ) ❑Complete System O Individual Components
Location Address or Lot No. ��QGO �✓ L�'`• Owner's Name Addres and T No.
Assessor's Map/Parcel,�.7O
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
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 gallons per day. Calculated daily-flow gallons.
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 Certifi-
cate of Compliance has been issu y t ' B d Health.
Signed Date���
+ Applicail Approved by Date
TM Application Disapproved for the following reasons r
' s
If
Permit No. F' ! Date Issued
,THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO C �IFY, thatt W ite ge Disposal System Constructed( )Repaired ( )Upgraded(
Abandone�� )by '" o�
at 0t1i � '� L s bwf n const tied in j�ccordance
with the provisions of Title 5 and tthhe f Disposal System Construction Permit No. �dt'j � � r dated a'a/U�
Installer Designer /
The issuance opf�tale U t'rall not be construed as a guarantee that the sys m t11 foction as igne�l a
Date ! Inspector `""1 ` v,
�-o�y - y.9�---------------------------,-/off-
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
li0pogar *pgtem Construction Permit
ion tr ct Repair( ,),Upgrade Abandon(
)Permission is hereby grpcd
Kd!�System located at ' ��
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 conditio s.
Provided:Construction must be�completed within three years of the date of this p t.
Date:_. C 1 G I Approved by
/ TOWN OF BARNS'TABLE
LOCATION' SEWAGE #
VILLAGE ��y/��'�'�f' ASSESSOR'S MAP &LOT 70 �o
INSTALLER'S NAME&PHONE NO. �' Ztr'B��yF �'�� O7_
9 ,
SEPTIC TANK CAPACTTY �'
• LEACHING FACILITY: (type) (size) �-3 y"A
-7 e vo SXZ C-0—C-0too '
NO.OF BEDROOMS CG,yi..�c�/.tn►er�e�t�'
BUILDER OR OWNER
PERMTTDATE: 9—_�'o y COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and 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 my wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
A
� /'r31s a 4
iAvv
Sep 22 04 07: 44a 508-033-2177 p. 1
Town of Barnstable
.. r Regulatory Services
Thomas F.Geiler,Director
Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Fax: 508-790-6304
Office:.508-862-4644
Installer&Designer Certification Form
Date:
Designer
Installer: h7 Z ewa
Address: . Address:
was issued a permit to install a
(date) (installer}
septic system at based on a design drawn by
(address} '
"�v� �, ►'1 ' dated
(designer)
T certify that the septic system•referenced above was installed substantially according to
the design, w$ich may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. .
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with State&Local Regulations. Plan revision or
certified as-built by designer.to follow.
taller's Signature)
(Designer's Signature} (Affix Designer'ss Stiasiip Ilene}
PLEASE RE TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF AS-
BOTH FORM AND
COMPLIANCED BY THE BARNS'
E PUBLIC HEALTH IVISION.
BUILT CARD ARE
THANK YOU.
Q:Health/SepticMesigner-C6d6raeon Form
i
TOWN OF BA.RNSTABLE
LO ALION SEWAGE #
VILLAGE ASSESSOR'S MAP & LOTS?20 3010
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY � � C7A/,
LEACHING FACILITY: (type). Q 6X(V (size) S/ O✓t2
NO. OF BEDROOMS 3
BUILDER OR OWNER Yl l'�
PERMITDATE: 'COMPLIANCE-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 1 aching facility) l Feet
Furnished by $'< i�_!n_S�Iet,T30r1 roe-
�� 3
O
i�
Qc
00
cb d
1 1 nMMM
v C =
s � C = � • O �,,.
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C '
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�Z21.... Fps.... ®
Y40............ . .. ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR HEALTH
�n
-- . .:-cJ'LCJ► ......OF............ .ct,�c0.- .......
Appliration for Uiipa i al Work.5 Towitrurthin rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
pp�n Loc -Address p, or Lotp No.
y��
�.
---•• -�'`i—"" 9 �'""' T la.w= ��aS..----...-•--•--•-- .................`f_. �.. _..Sr�rl. .. .Lsiav�-•-------••- ---.....--"-----•-
wner Am ss
W
Ins Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
a' Other fixtures ............................ .
W Design,Flow.....I. o............................gallons per person day. Total daily oyy-------
340.......................gallons.
.�:
W Septic Tank—Liquid capacity...... allons Length.. ........... Width--.V.Y.- Diameter--------........ Depth.1563_01
_...-..
x Disposal,Trench—`40..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.------t----------- Diameter.----7............. Depth below inlet.... I........... Total leaching area.. `c;... .sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
a Test Pit No. lb' -------minutes per inch Depth of Test Pit......A..t...... Depth to ground water...4 .-.
f� Test Pit No. 2................minutes per inch Depth of Test Pit----................ Depth to ground water........................
a 7.......................... �f------------- - ---- •
-----------------.----------------------
----------- -
O Description of Soil---••-- :..._`
W
UNature of Repairs or Alterations—Answer when applicable................................................................................................
-----------------------------------------------------------•------------------...--•-----------------•-•----•---•-••-----•-••---••-•----------•--•--•---•-••----------•-----•--------•---...•-•••-••-•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of'I'LL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
• .. ----- _.. -----------------------• ..... ...
Application Approved By-- •• 7.. _..._
Date .
Application Disapproved r t ollowing reasons---------------------------------------------------------------------------------------------Da.t e----........--
-•.--•--------------•--.---------•--•--------•--•---.........-----.--.-------•-•-••-------._................................••---.---------.---.--................................. -----••-•-•---
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARB-Gf HEALTH
-:........OF............ ,.......
,
ApplirFa#ion for DiipnsFal Works Tnnotrurtiun rumit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
...............W.A.%ay..�.4.4 �e. . A
................
Loc Address ' 10t No. ---
�. Owner - A82tres���-
W -. r.............................. ......•• 4.. .... :..•-- ... � �... +,
'-� Insi I Address
TypAf Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
al Othe fixtures
--------------
W Design Flow---- -•••-••...................•gallons per personpa%AAy. Total d jYf � 1, .... _ l�r}s.
WSeptic Tank—Liquid capacity...*f allons Length___ __________ Width__.. ..._ Diameter-------_........ Depth__......
x Disposal Trench—No..................... Width_.___------------. Total Length...... ...I____.... Total leaching area______ ___..._._._sq. ft.
Seepage Pit No.......I........... Diameter.._77.._..._. Depth below inlet.... Total leaching area...�.� :sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by---------------------------- ---=--------------•_._..,......__._-------- Date.................... ---
Test Pit No. 1 i_____________minutes per inch Depth of Test Pit........__.......... Depth to ground water....
fp�s//, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-_.__.............._...
►+.I _.. .. ......................'__*' A's____ . ...................... �,,.. ..
O Description of Soil `" ~�- � ` _ d - fir....�--.
W
UNature of Repairs or Alterations—Answer when applicable................................................................................................
-------••--•--•---•••-•---••-•••-••--••--••--••--•----••••----•••.....•-•----•-•••••................•-••--•--•••--------------••----•••-•-••••••••••---••----•-•-•-••-•-•-••••-•-•---•-•------••••---•--
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITHE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
-'Sig d'` '��... ... ..... ......................... .......... ........... ----
Application Approved By....... /
Date
Application Disapproved fpr th oRowing reasons:.. - :..._
•---•-----•-••••-••----•-_.........•-••-.....___...•-••--••-_.........•-•--•--•••--•---------•--•-••---_.._........••••----••----••••----•--•-----••--••••-•----•-••-----•-•--••-••--•--•---••-----------
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
Z (Irr#ifiratr of Tolatlrlianrr
THIS-IS/:',
TIFY, That the Individual Sewage Disposal System constructed ( or Repaired ( )
by.............t1 -- ---------------------------- r^
4- 1 t er
at_...... ..�C"... �•------ -- rl/ / `i4......--- •------------- --------------------------•-------•-------•••----------. ..................
---- ------
has been installed m accordance with't11. provisions of TITIF 5 of he tate Sanitary Co e�s de'r' ed in the
application for Disposal Works Fonstr.ction Permit No.__.....�.3_................... dated_... _.�� �_.......................
THE ISSUANCE OF THIS-CERTIFICATE SHALL NOT BE CONSTRUED AS AGUARANTEE THAT THE
SYSTEM WIL U TION SATISFACTORY.
DATE--.ID...f:.. --7--------•................................................ Inspector--•--- -•------- •...............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
a .......................................OF.....................................................................................
No.... _". FEE........................
Permission is hereby granted.-...-!.�`�C �!-'az<....-..-- �'
.......•••....................
to Construct ( o Repa>,r,( a Indiyldu'90Sewage Disposal System
--
I Street ,.
as shown on the application for ispo o.. s struetion Permit No............... f"ated..........................................
' -,'
DATE---------•----••••-••••......---.--•-• ... ................ ••...... f Board of Health
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
r:
uo GAIzeAGE 6QJWP61'2. \v
�I
n�« F.L�w PP 'I
SEPTIG TP►•JK = 330xl5C"0/-
= 497G.P o t• �i
v5E- 100o
015Po5nL PIT v5E ivo0 GAL• i,
S ►DCWAt.L Peca - i�o S.r-: 11'' : . I'
150 5.t= X
BOTTOM A2EA= .. lro 5•F• F
JI
-ToTA I,- DS51GN = 422 G.R D.
I -Tc-TAL DA I�-%,( PLOW00
= 33o G.Po �;s 9BN
PP-P-COLAT1414 RATE : I"IN ?-PAIN
t Q
• .o• Fi,/p `' �, Soo 9�
�1N Of M I� `
tN Qf +M1 �� �sy /oo o c
RICHARD cyGs �a� ALA N nN 98 g ZVI- `
A. ►.,1 W. nl
BAXTER y (yes
i 4hD SUR��+� OM
17,9
'T
I , ^ ^ , --
��y¢ loov INq�•
DIST. qIN�. �Co
/7�
I oao
l� GAS..
G•�t►�` LeActl
PIT INV. INV.
G ' WITu '•5 9G 7
WAS4 D
C�v�SC' 6Tv N E
GEz-rIFtGD PLo"T PLAw
BG.3 PRUFIL. L06A-r10N �,✓,c/%S
wo SCALE ScAtE /':- � SATE 9118.3
P L-A N FZ E F E tZE N GE
C E RT%P`! T N AT T N a e-,et r16 �-+�►'�SµO�N � � � �v
NE2EoW GoMPLY5 WITH -THE 4 oT
4
Aug 56T5AGK 2sRL)►2.lccMEN7't�' of ZNE' wP0
-Tow N o I=C3AQnl s-ra3 L&
LOGp. E WtTNIQ N'E FLoao /P�LAIt4
DATE4 BAXTE2a N`(E INC.
REG I SZ�Q6•� 1-A.N�S u izY E`�oeS
TI115 PL�►�I I �j N� 4�5�n Ord AN OSTEiZVILLr-- MA55
(� 1u5-1-R,UMENT T V ZVC-Y F -T
NoT P�F- u5ED Cd VETEW�IN� 1 .oT t- IfdE � pPLIG /� ►-r'r
�706P
BORTOLOTTI CONSTRUCTION,INC.
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 ®r OCT 2 .1 `
508-771-9399 508-428-8926 FAX: 508-428-9399 -•
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATI N
Property Address: 6 Lo/)e
Date of Inspection: (b—/"' Ins Inspector Name:
Pe
Owner's Name and 4dyiress: r
P.
CERTIFICATION STATEMENT*
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,.accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal stems. The System:
Passes
Conditionally Passes
Needs Further valuation By the Local Aproviug Authority
Fails
Inspector's Signature: Date: /6 A0
The System Inspector shall submit a copy of this inspection report to the Approving authority within thir-
ty(30)days,of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
A)SYS M PASSES:
I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair, passes inspection.
Indicate yes, nor,or not determined(Y,N,OR ND). Describe basis of determination in all instances. If
."not determined",explain why not.
The septic tank is metal,cracked,structurally unsound, shows substantial infiltration or
exffltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup 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 mieveu distribution box. The
system will pass inspection if(with approval of The Board of Health);
- l - I
I
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
:.PART A
CERTIFICATION(continued)
Broken pipe(s)replaced ,
Obstruction is-removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
`The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
C)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 the public health,safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD,OF IIEALTH DETERMINES THAT.THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH"(AND PUBLIC.WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS.FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT: ,..
The system has a septic tank and soil absorption system and is within 160 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply.well.
t The system has a septic tank and"soil absorption system and is within 50 Feet of.a private
water supply well:
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well, unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and.the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. .
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool. =
Discharge or ponding of efluent 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 clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2
day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed -
pipe(s). Number of times pumped
-2-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PA RT A.
CERTIFICATION (continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply. .
Any portion of a cesspool or privy is within a Zone.I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliforrn bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above: -
The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because.one or more of the following
conditions exist:
The system is within 400 Feet of a surface drinking water supply
The system is within200 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 I1 of a public water supply well.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CMR 5.00 and 6.00.. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:1/Pumping information was requested of the owner,.occupant, and Board of Health.
_None of the system components have been pumped for atleast 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.
&/As-built plans have been obtained and examined. Note if they are not available with N/A.
_LjL`rhe facility or dwelling was inspected for signs of sewage back-up.
✓The system does not receive non-sanitary or industrial waste flow.
1/The site was inspected for.signs of breakout.
_ All system components,excluding the Soil Absorption System, have been located on site.
_J"rhe septic tank manholes were uncovered,opened, and,the interior of the septic tank was in-
s ted for condition of battles or tees, material of construction,dimensions,depth of liquid, .
epth of sludge,depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3
- i;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CIIECKLIST(cowinued) .
V The facilih'owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORM'ATIION:'`
FLOW.CONDITIONS
RESIDENTIAL // ,,
Design Flow: gallons Number of Bedrooms: Numbcr of Current Residents VGe
Garbage Grinder: Affi Laundry Connected To Syste I 111Yy.S— Seasonal Use:
Water Meter Readings, if available:
Last Date of Occupancy: '_5- ol7� S OmC' r rn
COMMERCLAI/INDUSTRI_AL•
Type of Establishment:
Design Flow: gallons/day Grease Trap Present:(yes or.no) .
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings, If Available: _ Last Dale of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of informs on'T g d /��
System Pumped as part of iiispection:NC)__ If yes, volume pumped; gallons
Reason for pumping:
TYPE F`SYSTEM: ,
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records,if any) s.
Other(explain):
PROXIMATE AGE of 11 c 1ponents,dale installed(if.known)and source of information: '
Sewage odors detected when.arriving at the site:
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM .INSPECTION FORM
PAR'r C
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grade Material of Construction: t/concrete metal FRP Other
(explain). .
Dimisions: ' ' ' Sludge Depth: _Scum Thickness:
1p-
Distancefrom top of sludge to bottom of outlet Lee or baffle: 6 ��
Distance from bottom of scum to bottom of outlet tee or baffle: '4119/7 e
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation W outlet invert,structural irate r'ty,c 'dence of leakage;etc.) Od
„sond
o Q
GREASE TRAP: Nd
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain)
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping,.condition of inlet and outlet tees or ba.fhes,depth of liquid
level in relation to outlet invert,structural integrity,evidence of leakage,etc.)
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction: concrete_metal FRP Other(explain)
Dimensions: Capacity: _gallons Design Flow: gallons/day
Alarm Level:
Comments:.(condition of inlet lee,condition of ►farm and floarswitches,etc.)
DISTRIBUTION BOX: (/Depth of liquid level above outlet invert: 4)6"r � 2
Comments: (not evel and distribution i ual,cvi(Nice of olids carryf)ver,evidence of le< age ito
or ut of )o� —
PUMP CHAMBER:
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.)
-5-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS):
(Locate on site plan,if possible;excavation not required;but inay be.approxintated by non-intnisive
methods) If not determined to be present, explain: _
- I
Type: ,
Leaching pits, number: Leaching chambers, number: Leaching galleries,number:'
Leaching trenches, number,length:
Leaching fields, number,dimensions:
Overflow cesspool, number:
Comments: (note condition of soil igns of hydraulic failure level of�o g, ondition of vegetation,
etc. (�O�J �G 6te- l �- t 60� JC
CO rrCo-de
tJ'J.
CESSPOOLS:
Number and co figuration: . Depth-top of Liquid io inlet invert:
Depth of:solids layer: Dcpth of scum layer: Dimensions of Cesspool:_
Materials of construction: Indication of groundwater:
Inflow(cesspool must pumped as part of inspection) -
Comments: (note condition of soilk,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dimensions:
Depth of Solids: Y .
Comments: (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,
A
etc.)
-G
I .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks:
Locate all wells within 100 Feet.
01
u ;Co,,
5
DEPTH TO GROUNDWATER:
Depth to groundwater; /6 Feet
Method of Determination or Approximation: a
-7'-
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 68 Wagon Lane
Hyannis, MA-02601
Owner's Name: Narinder Thind
Owner's Address: Same EQ
Date of Inspection: August 21, 2001 TO JU� 29200,
- w�of
Name of Inspector: (Please Print) James M. Ford yFgt H p�STq
Company Name: James M. Ford
Mailing-Address: ; `% , P'O: Boz 49' !' f ' ''x" FMapc"270'
Osterville,MA 02655-0049 Parcel.206
Telephone Number: (508) 862-9400
sit ,A'_. ..j,, •
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accivate`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 -
Cond• i ally Passes
N 174ther Evaluation by the Local Approving Authority
ails
Inspector's Signature: Date: August M, 2001
The system inspector shall subm 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_
I.. ,+i ... .. ,.. .. ._ - .. ,. ,- - ,- s 1. yes•_ .-f i,
authority. Y
Notes and Comments
****This`report*onlydescribe's 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 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.SEWAGE.DISPOSAL,SYSTEM INSPECTION FORM
... '� PART A INSPECTION
CERTIFICATION, (continued)
Property Address: 68 Wagon Lane
Hyannis, MA _ . ._�.-• � i.,,.�z ,}
Owner: Narinder Thind
Date of Inspection: August 21, 2001
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 ecompletion of the replacement,or repair;as approved by the Board of Health,will pass.
Answer yes,no-or notdetermined(Y,N,ND) in the for the following statements. If"not determined",please
`explain`;.lur'_• f> .ly ','�"r• ' :?':, � :,.; >N F ,ll'; •, _ .. ..
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system ire requd 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:
2
Page 3 of 11
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
; •�' CERTIFICATION' (continued)
!a>.,5�'� -l.Z`S}� •:CST c "n: '(.� :a}'.
Property Address: 68 Wagon Lane
Hyannis, MA
Owner: Narinder Thind
Date of Inspection: - August 21, 2001
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2 'System will fail unless the Board of Health'(aud Public V to Suppliei,if any)determines that thet
system is functioning in a manner that protects the public health,safety and environment
MI ..Ji'.i_ ... . ....aft.J _ .. � .t _^ J:. ! ��:. ..>."j F: to" � �''�:e ,i:.,_ .�...n.VILr`�r
_ 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.
r `The system ha`s a"septic tank and SAS and the SAS is within a Zone 1 ofa'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
* `TiiiS SySt passes I the Well water a iaiysgS,'rerforn:ed at a yBP certified laboratory, for..c^I r^'
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:
i'
- , - � t.�.5..'ac.:." ...,,�•L:.�}f 1 1`J ' �:.+;. i i}�'{A�..�..,>..�a.I2.{-•s 4.�-Q
r ,-
3
4
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
s' CERTIFICATION (continued)
Property Address: 68 Wagon Lane ;z
Hyannis MA
Owner: Narinder Thind -
Date of Inspection: August 21, 2001
D. System Failure Criteria applicable to all systems: .
You must indicate either`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 liq
uid 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 groundwater elevation.
` ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
"✓ Any portiori of a cesspool-or'privy is within a Zorie41 of a public,well. r.
_ ✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well. y'
_ ✓ 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 DEVicertified 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.]
No
ri exist as
that one or more of the above failure criteria e
(Yes/No)The system fails. I have determined t t
�
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 System:
To be considered a large system the system must serve 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 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.
4
Page 5 of 1 I
. OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
" PART B
CHECK-LIST
-
Property Address: 68 Wagon Lane -__ �s,:� .zr�� .��,..�.,_ •��• T��,� v f•a:�:.
Hyannis, MA
Owner: Narinder Thind
Date of Inspection: August 21, 2001
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 o .dwelling inspected.for signs of sewage-,back,up:?r (Owner not home)
,'ice r s .t-• `�d U. .-.� ... i !i. iit[�::Y. :It: d "i.,.£3. +.. ."? .,.., (A' ri:3 .. '
v a✓� . -""F Was'tfie'+site insspectWd for signs of break out?,f , A
r.
Were all system components;'excluding the SAS,located owsite,?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition_ d
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:
Yes No
✓ 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(3)(b)].
4..) i i.'7.a. Sjf: 11 ! �f «.....�._. ... _
5
k
Page 6 of 11 .
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
. .SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
�SrYSTEM.INFORMATION
Property Address: 68 Wagon Lane
Hyannis,'MA
Owner: a Narinder Thind -
Date of Inspection: August 21, 2001
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 4
Does residence have a garbage grinder(yes or no): No
Is faun<dy on a separate sewage system (yes or no): No_ [if.yesseparate inspection required].. ...
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No 1
Water meter readings, if available(last 2 years usage(gpd)): 2000-118,500 gals.; 1999-98,250 gals.
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COIVEWERCIALANDUSTRIAL
Type of establishment:
Design flow<(based on_310yCMR 15.203) gpd
'Basis of design flow,(seats/persons/sgft-etc):"7n.
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), Y4r
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
- GENERAL INFORMATION
Pumping Records
Source of information: Pumped on July 29196-per treatment plant
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
✓ 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-andmaintenance contract(to be
obtained from system owner) _._ s-V.
Tight Tank Attach a copy of the DEP approval.
abther'(describe):>+...118,T"
Approximate age of all components,date'installed(if known).and source of information-
Oct 11183-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
f ' SYSTEM INFORMATION (continued)
Property Address: 68 Wagon Lane
Hyannis, MA
Owner: Narinder Thind
Date of Inspection: August 21, 2001
BUILDING SEWER(locate on site plan)'
Depth below grade:
Materials of construction: _cast iron ✓ 40 PVC _other(explain):
Distance from.private water supply,well o suction line: . ?.
Comments(on condition of joints,_venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 12"
Material of construction:. ✓ concrete _metal _fiberglass polyethylene__
_other(explain)
If tank is metal list age: ,;1s age_confirmed,by_a Certificate,of,Compliance(yes or,no) -nrl(attach a,copy;_of
certificate)
Dimensions: 1000ga1. .....�._. , ..� .., ,.;�>M �; ��:_,,,
Sludge depth: 2„ cur; , p< )ate t.�_: -$.�, ;r:- } ;. -Ni
Distance from top of sludge.to bottom.of.outlet tee or,.baflle:- 30"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum td bottom of outlet tee or baffle: 11"
How were dimensions determined: Measuring 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.):
The tees were present .The liquid level was even with the outlet invert. There were no signs of leakage. Scum and sludge were
minimal.
GREASE TRAP:-_None (locate on site plan)
p I
Depth below grade: ,
Material of construction: _concrete _metal _fiberglass _polyethylene _other
(explain): ,
Dimensions:
Scum thickness:
Distance from#op of scum to top'.of_outlet.tee-or baffle:. : •": 1:. .;;��„ :.,: .. , „ ,. .; .�A =r;,
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.):
7
Page 8 of 11 a r
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
v }:t'SYSTEIVI'INFORMATION (continued)
Property Address: 68 Wagon Lane
Hyannis, MA r _....
Owner:, Narinder Thind .. _ .
Date of Inspection: August 21, 2001
TIGHT or HOLDING TANK: None (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 B.OXSSY` _✓'^'(ifpresent'must be opened).(locate on--site j)lan)Depth of liquid level above outlet invert: --
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was located but not duz up There were no signs of failure in the leach pit.
PUMP CHAMBERS None (locate on site plan)
Pumps in working order(yes or no): _ t.
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
;4 7�`J, ,:�y;a.`."��r•ii.3 t:,.tt±l,". z!'.it�:;€3,;+:.• n F. F ..fl: .. s '`dry r t �� � . .. - ....
8
Page 9 of 11
r
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
:SYSTEM`INFORMATION (continued)
Property Address: 68 Wagon Lane ?� �ac__. = ;. ,�•:t ::� 'J..;,;i a`
Hyannis, MA
Owner: Narinder Thind
Date of Inspection: August 21, 2001
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type ,
✓ leaching pits,number: 6'x 6'with]'stone(per design plans)
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.):
The pit had 2'ofwater on the bodoin.-..The scumline.was approximately.3!.up from.th_e bottom. There;were-no signs offailure.
The bottom to grade was approximately 7.S'.
CESSPOOLS: None (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: 1 .
Indication of groundwater inflow(yes or no): _
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition'of vegetation,etc.):
PRIVY: None (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.):
9' ,
n
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
t.. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM,INFORMATION (continued)
Property Address: 68 Wagon Lane _`, x' tcll `S 6
Hyannis. MA 04
Owner: Narinder Thind
Date of Inspection: August 21, 2001
Map:270
Parcel:206
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.
n r
R"' �af.'t'�. ,. C`i i"+.,- :' ':.7 r�. !'`t',i'`"1�5 2. '�+i4s 1�'" cv' «� .•,tg• S*. r' 't._. � _ _.+ns - h.,
- 3
A,9 31
(33- 3y
4Z n A s� ,t:'F S4 X.
10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C _.
SYSTEM INFORMATION (continued)
Property Address: 68 Wagon Lane
Hyannis, MA
Owner: Narinder Thind
Date of Inspection: August 21, 2001
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 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:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic&water contours maps
Checked with local excavators,installers-(attach documentation) R
Accessed USGS database-explain: {
You must describe how you established the high ground.water elevation:
The bottom of the leach pit to grade was approximately 7.5'., Using the Barnstable topographic map and the Cape Cod
Commission water contours map the maps were showing approximately 30'+1-to groundwater at this site. Using the Cape Cod
Commission Technical Bulletin, the high groundwater adjustment for this site(A1 W 230, Zone D, 7/01)was 5.2.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
N. 11
,"
� . - ( _ � � `
. ' � `.
� �
I
' - � O — -- I
� � s._.
� --�
c c r
• ,L � �
A � �� c y
` � s *-�
F �
-�. 4, `.
w �
c
o c
• �.
,, v
�..�
0
,,
. ,,
I
ASSESSORS MAP: `27p --- TEST fHOLE' LOGS
PARCEL: "�.Z �-------- _ _ _--- *.
NOTES:
SOIL EVALUATOR: IfJ f I IA iA G
FLOOD ZONE: lla -._ _
fj+ WITNESS:
MOAt
REFERENCE: DATE. 1) The installation shall com 1 with Title V and Town of Barnstable Board of
PERCOLATION RATE: comply
Health Regulations.
_ ��� -- --- -� ,� 2) The installer shall verify the location of utilities, sewer inverts and septic
TH- I TH-2 components prior to installation.
V, _
3) All gravity septic piping to be 4 inch Sch 40 PVC at 1/8"per foot.
4) This plan is not to be utilized for property line determination nor any other
3 Purpose other thillAt a proposed system installation.
5) All septic components must meet Title V specifications.
s g ��3 ley 6) Parking shall not be constructed over H10 septic components.
LOCAT I ON MAP ( , t5►� r r
7) The property is bounded by property corners and property lines as depicted.
t Yl } �1 # 8) The Property owner shall review design considerations to approve of total
number of bedrooms to be considered for design. Receipt of payment for the
'/� plan and installation based on the plan shall be deemed approval of the
V`� �✓� J ►� number of bedrooms.
9) The existing leach pit shall be pumped and backfilled r Title V
Abandonment Procedures.
� � 10)Proposed leaching is to be within 36 inches of grade or provide venting or cut
grade as permitted by the Board of Health
r l �/ 11)System components to be 10 feet from water line.
i 12)Septic tank to be a minimum of 1000 gallons. If tank is less than 1000 al.
SEPT I Q SYSTEM DESIGN then replace with 1500GST. g '
FLOW ES'3 I MATE -
BED'OOMS AT GAL/DAY/BEDROOM -?J GAL/DAY
54
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DBC ENVIRONMEN`fAL DESIGNS
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EAST SANDWICH . MA
W ( 508) 833- 2I77
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