HomeMy WebLinkAbout0088 WAGON LANE - Health 88 Wagon Lane
A= 270—208
Hyannis
TOWN OF BARNSTABLE �y
I:OCATION � EWAGE# OCA K I a Lr
VILLAGE I.A Noctml� ASSESSOR'S MAP&PARCEL.
INSTALLER'S NAME&PHONE NO. `' ""�1 F rs,- l t�L(C� CJ064
SEPTIC TANK CAPACITY A, I,O o(D'
LEACHING FACILITY: (type) �,� A Un, too 0 (size)
NO.OF BEDROOMS
OWNER-
6-� T
PERMIT DATE: klAZ 7 [ ( .COMPLIANCE DATE: 5
Separation Distance Between the: Z.
Maximum Adjusted Groundwater Table to.theBottom of Teaching Facility Feet
Private Water Supply Well and Leaching Facility(If any wells exist on
site or within 200 feet of leaching facility) A I Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
i
.o w
e
G d
No. g —0611) Fee /r6�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
2ppliLation for Disposal 6pstem Construction permit
Application for a Permit to Construct( ) Repair VUpgrade( ) Abandon( ) ❑Complete System individual Components
Location Address or Lot No. (�� do (_CrVZ/ Owner's Name,Address and Tel.No.
Assessor's Map/Parcel g,®
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
a SV4 Ouoi
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) JUA gpd Design flow provided AJA- 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) sit r\ jA--t Ct *-, o
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 this Board of Health.
#S' a Date -2ZO (g/
Application Approved by C►- Date
Application Disapproved by Date
for the following reasons
Permit No. ��/ �c �j Date Issued &e ��/j
r�. ., ..-mow... �. �.,.rtc-+.dbi."ti..1°- •M� ., a ,..r.�.;w, p-�y., a T, ... - .n.. y. ^'.1,j>�e< ,M,F�:�"t^. :.+.:.-..^` t ...-v^-
Noi✓v �1 r v Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .07
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ftplication for Disposal *pstrm Construction Vermit
Application for a Permit to Construct( ) Repair V,
Upgrade( ) Abandon( ) ❑Complete System 2Individual Components
Location Address or Lot.No. '� �� tln LGe\lf�- Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 9 7c) an tj
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(min.required) IVA gpd Design flow provided A)A- 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) LG�- \ S�c b�►"�'�G n ►U'
Date last inspected: '
E Agree'ment:
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 this Board of Health.
S'gnefi' -
Application Approved by - _ Date
Application Disapproved by Date
Ja-
for the following reasons
{Permit No. /�� � � � Date Issued � y
W THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance /
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(^✓) Upgraded"( )
Abandoned
�( )by �_r cl M -
at_ - CQj e_ .- ", /0 l T - - has been constructed in accordance
with the provisions of Ti le 5 and the for Disposal System Construction Permit No_.7,,0(R`04 dated
Installer Designer
#bedrooms A)j Approved design "flow _ - 1/P� gpd .
The issuance of this permit shall not be construed as a guarantee that the system function as designed. - '
Date ( �� J Inspector. -I
No. �l v ZG Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal *pstem Construction permit
Permission is hereby granted
to Construct( ) Repair V lUpgrade( ) Abandon( )
System located at t� �,,ace G� 1J t...CA'."t—
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Co
nstruc
t*
must be completed within three years of the date of this perm i
Date Approved by
.
J ,�a
r
Commonwealth of Massachusetts �-7Dr o26 8
Title 5 Official Inspection' Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
M 88 Wagon Lane I D
9 (XI)
Property Address h.
Fernanda Torres r�
Owner Owner's Name X)
information is :
required for every Hyannis Ma. 02601 8/27/2018
page. City/Town State Zip Code Date of Inspection
4aF
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information Q--k 3a��
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Sean M. Jones
use the return key. Name of Inspector
S.M.Jones Title V Septic Inspection
Company Name
74 Beldan Lane
Company Address
few
Centerville Ma 02632
City/Town State Zip Code
774-248-4850 smjonestitle5@gmail.com S14522
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:
Z Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
8/27/2018
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title, 5 Official Inspection Form
lf,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is required for every Hyannis Ma. 02601 8/27/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The dwelling located at 88 wagon Lane Hyannis is served by a Title V septic system consisting of a
1000 gallon septic tank, distribution box and precast leach pit. The distribution box was found to be
rotted and is being replaced with new, permit#2018-265
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
i
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is required for every Hyannis Ma. 02601 8/27/2018
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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
(P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is required for every Hyannis Ma. 02601 8/27/2018
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is Hyannis Ma. 02601 8/27/2018
required for every y
page. Cityrrown 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-
1 0,000g pd.
❑ ® 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 16,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is required for every Hyannis Ma. 02601 8/27/2018
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
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd
I
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i4 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is required for every Hyannis Ma. 02601 8/27/2018
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: vacant 3 months
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes- ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is required for every Hyannis Ma. 02601 8/27/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: tank pumped at time of inspection
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1000
gallons
How was quantity pumped determined? size of tank
Reason for pumping: routine maintenance
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
I
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is required for every Hyannis Ma. 02601 8/27/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
original system installed 9/13/83. New d-box is being installed after inspection with permit#2018-265
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints ok, no leaks , vented through roof
Septic Tank(locate on site plan):
Depth below grade: 1
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 gallons
Sludge depth:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v 88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is required for every Hyannis Ma. 02601 8/27/2018
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
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
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
tank was pumped at time of inspection for routine maintenance and should be done again every 2
years to prolong the systems useful lifespan. Water level was even with outlet invert, tank was
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is Hyannis Ma. 02601 8/27/2018
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) '
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date.of last pumping: Date
Comments (condition of alarm and float switches, etc.):
Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
la Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is required for every Hyannis Ma. 02601 8/27/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box is rotted and is being replaced after inspection with permit#2018-265
i
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
"If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
� Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
(,w
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is required for every Hyannis Ma. 02601 8/27/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach pit was found dry at time of inspection with a stain line approx 4'from bottom. Pit was video
inspected from d-box.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid tolinlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
<io Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is required for every Hyannis Ma. 02601 8/27/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is required for every Hyannis Ma. 02601 8/27/2018
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
D
Z'co
fri �3 b 13
A
,A
�3
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owners Name
information is required for every Hyannis Ma. 02601 8/27/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12+
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6116 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
88 Wagon Lane
Property Address
Fernanda Torres
Owner Owner's Name
information is required for every Hyannis Ma. 02601 8/27/2018
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
i j L
a
� I
i
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t �
r � .
3ni' C.
931
L 0 CATION SEWAGE PERMIT NO.
• W7 -aoK
VILLAGE
ld-4 0::,X�- �
9� > .
INSTA LER'S NAME A ADDRESS
e UILDER OR �x OWN ER
DA T E P ERMIT ISSU E D
DAT E COMPLIANCE ISSUED o ,a
-No ...7 Fiz$.1....®..._...............
V THE COMMONWEALTH OF MASSACHUSETTS
gg a' BOAR® OF HEALTH
1.y o ...........n.w.."N............OF . . A.f.-?.JULY!9Bte..................................
Appliratiou for Dhipaii al Worko Tuustrurtion Urrmit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at:
................ ............... ............:Z 6 ' �� ..._�-f ig`vim C f .......-•-------
ion-Address or Lot No.
f.L. .�'. � .......--••--•--....... l �.t.G '. rS3�u�2.._.1 �.�^ - :...���:2
O er a Address
.... ..
I taller Address
T of Building tt�� Size Lot----------------------------
Sq. feet
Dwelling—No. of Bedrooms...._.?.................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons___-._-_•___________________ Showers — Cafeteria
Q' Other fixtures ...........____............................
w Design Flow.........tif l 4t.........................gallons per person p`r day. Total daily flow....S.s�............................gallons.
WSeptic Tank—I Liquid capacity../tv�lgallons Length... ........... Width__. �!o�"Diameter................ Depth '
x Disposal Trench— No. .................... Width..7................ Total Length.................... Total leaching area.: '....sq. ft.
Seepage Pit No..... __.. Diameter..... ........... Depth below inlet...�r............ Total leaching area..2.s=d....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed bY........................................................................... Date........................................
,..a Test Pit No. 1......-2.....minutes per inch Depth of Test Pit.................... Depth to ground water_-___-_____-____--_____.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
...........I-------- • ...
O ..............•---.'_.T.............�/-----•---�---•--..................------•----;-------•---- -.....-----•-----
Description of SOi---- ----------- r`�------.12-•--• �� D`I-- 0
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 TITU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has ben issued by jhe board o��f health.
!.�! ----•--------------------- !
Application Approved BY7the
---- ------•----•-------•----------•-•---••----.tlll��. Zl✓
Date
Application Disapproved f olowing reasons-----------------------••-------•---------------------------------------...--•--•------------------......--•-----
---------••----------•----------------•--••--•--•----------------•--•---•--•--------------...---------------------------•-----•------------•----------------•--------•----••---•----------••-•....------
Date
PermitNo......................................................... Issued.......................................................
Date
.. o. ..-731 Fn$..............................
I THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ .............................
.............................
firatiun for RaposFal Worku Tunuitrnnrtaon ratnit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System at: 10'
f
wl"c on-Address or Lot N
O er t . re
a ------------- - - .� .
I taller Address
� TyVof Dwelling Building Size
of Bedrooms.......................................... Size Lot............................Sq. feet
V ..Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers
a Other—Type g --------•----•-•-----------• P ( ) — Cafeteria
dOther fixtures --------------•--------------------•-............• ..............................................
W Flow...... f.O?........................gallons per person � gad Total daily fl�,w .. ------------------------------------------
Design ............................gallons.
WSeptic Tank—Llquld capacity_. _�allons Length............... Width-_: ......._ Diameter---------------- Depth.5............
x Disposal Trench—No. .................... Widt .r___.._.__..._._ Total Length...........
__----- Total leaching area..__---.--_-------..sq. ft.
Seepage Pit No......_ _ ... Diameter...... ............ Depth below inlet.... Total leaching area._:'X! ! ....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date...............
Test Pit No. 1..._._'":a_...minutes per inch Depth of Test Pit.................... Depth to ground water.....:..................
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
7 ......................... i .VI------------------------� ' .'....---•xDescription of Soil � -••-••- •Q 'Ob y
" {
•-- - ------------------ -
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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
1 has be issued by t e board of healt
operation until a Certificate of Compliance � � �
P P
•.
t ......... 7
Application Approved By.............-•-----• ........................................
Date
Application Disapproved for e following reasons________________________________________________ -••---•.............................••._. ___........._
...................................••--•••--•------•----•••••--------•---•••-•••--•---.......••-•--....•.-•-----•---------•---•---•-•-----------------•-••••-••-•-•-•-•--------•---•--••--•-••-••-•.....
Date
PermitNo......................................................... Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF..............................................................I......................
Qprrtifiratr of TonnpliFanrr
THIS.IS TWY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by------------- 1� ......... ......... .....!..__... ~'' td ter
--------/51_�--------------
has been installed in accordance with '11e ovisions of TITI - of:TkefState Sanitary Codb. :c in the
application for Disposal Works Cons a on Permit No......................................... dated_...._.___ __. .......................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL/Ftj
TION SATISFACTORY.
DATE -l� 1/� Inspector
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
f� �711 ...........................................OF......................................................................................
No....... ................ FEE........................
�iu�uu�a1 ��'rku���,�trnnrttiun rranit
Permission is her by- nted - ..
�� • ••••-•........•------•...._••-----------------
to Construct Indiv lu l/Sewage Dily I System
atNo.................. -r!__._......1Z..........-•---•------. a/ /.1.....--. --------------------------------------------------------------�- - -
� Street
r/F
as shown on the application for Disposal Work Co struction Permit ........... Dated................. ...........
•------------------- --------- ------------------------------------------
Board of Health
DATE.......................... _. 4.................................
FORM 1255 HOSES & WARREN. INC., PUBLISHERS
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is required for every Hyannis MA 02601 10/08/13
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael Kellett
use the return Name of Inspector
key.
Aardvark Environmental Inspections
ey Company Name
PO Box 896
Company Address
East Dennis MA 02641
City/Town. State Zip Code
508-385-7608 SI 3742
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:
t
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/09/13
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 DER.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.
I� 1s/3
t5ins•11/10 Title 5 Official Inspection Form:S Sewage Disposal System-Page t of W
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
s� 88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is required for every Hyannis MA 02601 10/08/13
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.).
Inspection Summary:Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
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 ex filtration 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):
F
t5ins-11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is Hyannis MA 02601 10/08/13
required for every Y
page. City/Town state Zip Code Date of Inspection
B. Certification (font.)
B) System Conditionally Passes(cunt):
❑ 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 Ell 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 obstructedpipe(s).The
Ys roq P P 9 Y
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑; Y ❑: N ❑I 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 mannerwhich 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
tvlrs i 1f1u Tale 6 Official inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
yt 88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is required for every Hyannis MA 02601 10/08/13
page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
ElStatic 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•11/10 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
requinform
r don is for every Hyannis MA 02601 10/08/13
required
page. City/Town state Zip Code Date of Inspection
B. Certification (cunt.)
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 east as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either"yes"or"no"to each of the following,in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply [
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone Ii of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is required for every Hyannis MA 02601 10/08/13
page. Citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner,occupant,or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,excluding the SAS,located on site?
® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank
inspected for the condition of the baffles or tees,material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
® ❑ Determined in the field (f 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 15203(for example:110 gpd x#of bedrooms): 330
t5ins•11/10 Tide 5Offcial Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is required for every Hy annis MA 02601 10/08/13
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings,if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 09/Q 3
DatCommerciaUlndustrial 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:
t51ns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
s
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is required for every Hyannis MA 02601 10/08/13
page. CitylTown state Zip Code Date of Inspection
D. System Information (cunt.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:'
Source of information:
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) (f yes,attach previous inspection records,if any)
❑ Innovative/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title S Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is Hyannis MA 02601' 10/08/13
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components,date installed(if known)and source of information:
09/13/83 per BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2.0
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.):
Septic Tank(locate on site plan):
Depth below grade: 1.5
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: 1,000 gal
Sludge depth:
4"
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is required for every Hyannis MA 02601 10/08/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness
3"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle 16"
How were dimensions determined? measured
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 tank was sound and tight with tees in place and liquid at outlet invert.
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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is required for every Hyannis MA 02601 10/08/13
page. City/rown State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,Structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches,etc.):
Attach copy of current pumping contract(required).Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 Official Inspection Fort:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is Hyannis MA 02601 10/08/13
required for every y
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cunt.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert even
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 box was level and tight with no sign of carryover.
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.):
Soil Absorption System(SAS) (locate on site plan,excavation not required):
If SAS not located,explain why:
t5ins•11/10 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is required for every Hyannis MA 02601 10/08/13
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1
❑ leaching chambers number.
❑ leaching galleries number:
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure., level of ponding,damp soil,condition of
vegetation,etc):.
This system has a 6'x6'precast pit surrounded by two feet of stone.There was two feet of liquid with
a stain line 22"below the outlet 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
up
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is required for every Hyannis MA 02601 10/08/13
page. Citylrown 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•11/10 Title 5 Official inspection Foam:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is required for every Hyannis MA 02601 10/08/13
page. Cityfrown state Zip Code Date of Inspection
D. System Information (cunt.)
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
t. ' rear
27
16
54 �
45 47
t5ins•f 1/10 Title 5 Offxial Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
"s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is required for every Hyannis MA 0260.1 10/08/13
page. City/Town state Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water: 20.0
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators,installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS maps show an elevation of over 20.0 feet.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sysbem-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t 88 Wagon Lane
Property Address
Lisa Aframe
Owner Owner's Name
information is required for every Hyannis MA 02601 10/08/13
page. Cityfrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17