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:� Commonwealth of Massachusetts
Title 5 Official Inspection Form
u
m Subsurface Sewage Disposal System Form-Not,for Volnta ;
• 9 p Y rY•Assessments
115 Wayland Rd
Property Address
Peter Gay
Owner Owner's Name
information is r
required for every Hyannis MA 02601 5-3-21_ r
page. City/Town t State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. Inspector Information S I
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
East Falmouth , MA r 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that:) am a DEP approved system inspector in full.compliance with Section 15.340 of Title 5
(310 CMR 15.000);l have personally inspected the sewage disposal system at theproperty address listed
above;the information reported below is true, accurate and complete as of the time of my inspection; and
the•inspection was performed based on my training and experience in the proper function and
' maintenance of on-site sewage'disposal systems.After conducting this`•inspe6tion'I have determined that
the system:
I 1: Passe0 ,.
r.2. ,❑ •Conditionally Passes ,., t.
13. �❑ Needs Further Evaluation by the,Local Approving.Authority ,.
4. ❑ Fails
r -
I spector'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 form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority. -
- Please note: This report only describes conditions at the time of inspection-and under the -
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.-7/26/2018. .., - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 •.
ele" Commonwealth of Massachusetts
Title 5 Official- Inspection Form
h► Subsurface Sewage Disposal System Form-Not for.Voluntary-Assessments +
i
115 Wayland Rd
Property Address
Peter Gay '
Owner Owner's Name
information is Hyannis'` MA 02601 5-3-21
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System'Pas`ses:
® 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. Anyfailu_re criteria not evaluated are
indicated below. `
Comments:
System is in good working order with no sign of failure.
i 2)', Sy1stem Conditionally"Passes:
❑ One or;more:system components;as described in the "Conditional Pass" sectionneed to be
t replaced or repaired..The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic'tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a'complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System•Page 2 of 18
cam° Commonwealth of Massachusetts
Title 5 Official Inspection ,Form
it Subsurface Sewage.Disposal System Form -Not for Voluntary Assessments
115 Wayland Rd
Property Address
Peter Gay
Owner Owner's Name
information is
required for every Hyannis- . 3 MA 02601 5-3-21
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.) -
2) System Conditionally Passes,(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass.with Board of Health approval if
pumps/alarms'are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
' ❑ broken pipe(s) are replaced ❑ 'Y ' ❑N ❑ ND (Explain below):
' ❑' obstruction is removed ❑ Y ' ❑N ❑T ND (Explain below):
a
❑''; f'distribution box is leveled or replaced ❑Y ❑ N ❑ 'ND (Explain below):
N. G
r
❑ 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 El ❑N ❑ ND (Explain below):
❑ obstruction is removed ❑Y ❑N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health: i
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is'failing to protect public health, safety or the environment.'
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303 1 b that the system is not functioning in a manner which will protect public e( �( ) y g p p l health,
safety'and the environment: ' ' - ' I-,
A
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t5insp.doc-rev.712 612 01 8• _ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 - ,
Commonwealth of Massachusetts
,w Title 5 Official Inspection Form
h. 01 Subsurface Sewage Disposal System Form--Not for.Voluntary,Assessments
115 Wayland Rd
Property Address
Peter Gay
Owner Owner's Name
information is - +
required for every Hyannis MA 02601 5-3-21,
page. City/Town ' State Zip Code Date of Inspection n
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface'water
❑ Cesspool or privy is within 50 feet of a bordering,vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment: a =
❑The system has a septic tank and,soil absorption system__($AS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
. ❑The system has a septic tank and SAS and the SAS.is within a Zone 1 of a public water
supply:
❑The system has a septic tank and SAS and.the SAS is within 50 feet of a private water
supply well.
❑The system has a septic tank and SAS and the SAS is_.less than 100 feet but 50 feet or
-more from a private water supply well".
Method used to determine distance:
"* This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other..,
• r t
4) System Failure Criteria Applicable to-All Systems: + =
Yod'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
t5lnsp.doc-rev,7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
;w, Title 5 Official Inspection form
' rl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
115 Wayland Rd
Property Address
Peter Gay
Owner Owner's Name
information is required for every Hyannis MA 02601' 5-3-21
page. Citylrown •. State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.) ,
-Yes No Iz
®' 'Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool `
Liquid depth in cesspool is less❑ than 6" below invert or available volume is less than '%Z'day flow '
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑. . ,®, , • Any portion of the SAS, cesspool•or privy is below high ground water elevation.
r ❑ ® Any portion of cesspool or.privy is within 100 feet of a surface water supply or
tributary to a surface water supply:"
Any portion of a cesspool or privy is within a Zone 1 of a public water supply
® well.
` ❑ ' " ® '`-Any portion of a cesspool or privy is'w'ithin 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 witli 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
„k , ., X, and chain of custody must be attached to this form.]•
The system is a cesspool serving a facility with a design flow of 2000 gpd-
„. _'❑.r .®ct• 10,000 gpd.
The system fails. I have determinetl;that one or more of the above failure
El. c ' " " '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
n :Fr u r -necessary to correct the failure. .,:
5) Large Systems:To be considered a large system the system must serve a facility with a design
flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"for"no"to each of the following, in addition to the
questions in Section CA. r K
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
f
❑ ❑ 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
t5insp.doc•rev.,712812018. __ Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5:of 18 ,. . ,
Commonwealth of Massachusetts -
,w; Title 5 Official ofispection, Form -
i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
115 Wayland Rd
Property Address
Peter Gay
Owner Owner's Name ~'
information is ,
required for every Hyannis !� MA 02601 5-3-21 '
page. City/Town State Zip Code Date of Inspection t,
C. Inspection Summary (cont.) `
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate yes or no for each of,the following for all inspections:
Yes No
❑f .0 r= Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were anygof the system components pumped out in the previous two weeks?
Y
v ®` 'Has"the system received normal flows in the previous two week period?
r ❑ �x 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) i
`❑, -Was the facility or dwelling inspected for signs of sewage back up?
.: '=''_�' "❑ r 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,
dimen"sions,'depth'of liquid, depth of sludge and depth of scum?
1 Wasthe facility owner(and occupants if different from owner) provided with
information on1he 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.
t ® ❑' 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)]
1._•, a .. - f . �'.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official- inspection •dorm
'I �► Subsurface Sewage Disposal System Form -Not for-Voluntary Assessments
115 Wayland Rd , r.
Property Address t -
Peter Gay h
Owner Owner's Name
information is required for every Hyannis 1, MA 02601 5-3-21 v: r
page. City/Town ,, State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flowbased on 310 CMR 15.203 (for,example: 110 gpd x#of bedrooms): 330
Description:
�. .1
1 ,
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ,; ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection
# 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:
.' . - ;* ;•fig
Sump pump? ❑ Yes ® No
Last date of occupancy: c a t 2021
Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts _' "'1 '' ' �, •` 14
Title 5 0TT"i 'ial, Inspecti-' n, r
i Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
115 Wayland Rd "+
Property Address 211
Peter Gay
Owner Owner's Name
inf3rmation is
required for every Hyannis t• = - MA 02601 5-3-21
page. City/Town State Zip Code Date of Inspection L
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
F
Type'of Establishment:''' + '`
Design flow(based on 310 CMR 15 203).
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ' 1, ❑ Yes ❑ No
' Water meter readings, if available:
Last date of occupancy/use: ><
Date
. }
Other(desc1ribe below):
3. Pumping Records: 1
Source of information:
N/A
Was system pumped as part of the inspection? ❑ Yes ® No
- If yes, volume pumped: gallons
f 4 How was quantity pumped determined? - -
Reason for pumping:
t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.Page 8 of 18
Commonwealth of Massachusetts t -
Vide 5 Official, Inspection .Fora
! �t Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
115 Wayland Rd
Property Address -
Peter Gay
Owner Owner's Name
information is Hyannis t MA 02601 5-3-21--
,
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System: ,•� .
® Septic tank, distribution box, soil absorption system ,
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator,under contract
❑ Tight tank.Attach a copy of.the DEP approval. ;
❑ ' " '' Other(describe):
Approximate age of all components, date installed (if known) and source of information:
1982
Were sewage odors detected when arriving at the site? - ❑ Yes ® No
5. Building Sewer(locate on site plan): • ,,.
24rr
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.):
Good condition.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
s Commonwealth of Massachusetts
Title 5 Official Inspection FOVm'
�al
- h► Subsurface Sewage Disposal System Form=Not for Voluntary Assessments
<T
115 Wayland Rd r�r
Property Address
Peter Gay
Owner Owner's Name
information is
required for every Hyannis MA 02601 5-3-21'
page. Cityrrown` State Zip Code Date of Inspection
D. System Information (cont.) °t
6. Septic Tank(locate on site plan):
Depth below grade-
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:1
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: i 1000 gal
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or,baffle
20"
Scum thickness 0
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 16" ,.
How were dimensions determined? YTape
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.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
f
Commonwealth of Massachusetts W.-
�'. Title 5 Official Inspection •dorm r
r°I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments -
115 Wayland Rd
Property Address
Peter Gay
Owner Owner's Name
information
required for every Hyannis MA 02601 5-3-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) .,.. T
7. Grease Trap (locate on site plan): n
Depth below grade: feet
,., .., Material of construction:, L
❑ concrete ❑ metal ❑ fiberglass [I 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: , 1 ' . - , $' f Dafe"
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related-to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank (tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts � -•. �f
Title 5 Official= Inspection' Form
0i Subsurface Sewage Disposal System Form=Not for Voluntary Assessments - 1
115 Wayland Rd ,' ;
Property Address
Peter Gay
Owner Owner's Name
information is
Hyannis
required for every �` . MA 02601 5-3-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank (cont.) I *', •'
Alarm present;, El Yes ❑ No
Alarm level: Alarm in working order: • ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alarm and float switches, etc.):
*Attach copy,of current pumping contract (required). Is copy attached? '❑ Yes ❑ No
9. Distribution Box(if present must be opened)(locate on 'site,plan): #
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 with no sign of back-up from pit.
1a
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
i. Commonwealth of Massachusetts
�.\.
r rp Title 5 O64icia�l Inspection. Fo'Vm
!} .c°I Subsurface Sewage Disposal System Form -Not for:Voluntary Assessments
r� K�
115 Wayland Rd ,
Property Address
Peter Gay
Owner Owner's Name
information is MA 02601 5-3-21,
required for every Hyannis ,
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps inworking order: " ❑'Yes' El No*
. .
r
Alarms in working order: 'F' `° '❑ Yes` ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
" If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
r Type: '
leaching pits r number: 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 w
Commonwealth of Massachusetts �f�' '` } :; °"' _�- • -
��� Title 5 Official Inspection. I=or3 `
! Ill Subsurface Sewage"Disposal System'Form'-Not for•Voluntary'Assessments
115 Wayland Rd t
Property Address
Peter Gay
Owner Owner's Name
information is
required for every Hyannis MA 02601 5-3-21'
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) F . • f
11. Soil Absorption System (SAS) (cont.) 1
Comments (note condition of soil, signs of hydraulic failure jevel of,ponding, damp soil, condition of
vegetation, etc.):
Leach pit was in good condition and empty at inspection with stain line at 16" below inlet invert.
7 r
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration - t, , - . .• -` -
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
I Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.): f a . .
n
r.i r
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
ra Title 5 Official- Inspection Form ,
� f Subsurface Sewage Disposal System Form -Not for Voluntary Assessments. r
e
115 Wayland Rd
Property Address ,.
Peter Gay t
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
l L
Materials of construction:
Dimensions
Depth of solids f t
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
t
i
t5insp.doc-rev..7/28l2018., a, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 ,
Commonwealth of Massachusetts .• - -
Title 5 Official anspec$ion f&m
h► Subsurface Sewage Disposal System Form-Not for Voluntary Assessments J• =
115 Wayland Rd -
Property Address
Peter Gay
Owner Owner's Name
information is required for every Hyannis MA 02601 5-3-21
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate_ where public water supply enters
the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
h•
6J
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
sue,° Commonwealth of Massachusetts i
Title 5 Official InspectionFloirm
p Subsurface Sewage Disposal System Form -Not for Voluntary Assessments +
115 Wayland Rd
Property Address
Peter Gay
Owner Owner's Name
information is required for every Hyannis a MA 02601 5-3-21
page. City/Town r State Zip Code Date of Inspection
D. System Information (cont:)
15. Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: +
feet
Please indicate all methods used to determine the high ground water elevation::.
❑ Obtained from system design plans on record
• If checked, date of design plan reviewed: • Date
® Observed site (abutting property/observation hole within 150 feet,of SAS)
® Checked with local Board of Health-explain:
® Checked with local excavators, installers- (attach documentation)
® Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
USGS and town maps show groundwater at greater than 20'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc-rev.7/26/2018 .. _v` e i r Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 ..
C < Commonwealth of Massachusetts - - -
Title 5 Official Inspection f or
0 Subsurface Sewage Disposal System Form =Not for Voluntary Assessments
115 Wayland Rd '
Property Address
Peter Gay '
Owner Owner's Name
information is Hyannis - r MA 02601 5-3-21
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D.tSystem Information:,,: '-
For 8: Tight/Holding Tank-Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg.. 16 or attached
For 15: Explanation of estimated depth to high,groundwater included
. f� •' - 1 itit '�• `fir v a..
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
�Y� �
INST -A LlER'S N A N E A ADDRESS
5- 3
U I L H R ON OW ER
SATE PERMIT �155VE 3 AFe
TE COMPLIAHCE ISSUED' � 2,,3 �� .
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ASSESSORS MAP NO: _
No. �.... PARCEL NO.: - F�$ ..:.. � .....
t
THE COMMONWEALTH OF MASSACHUSETTS
f BOARD OF HEALTH
....................... ............... ............_......
Apptiratiou for 11i5paaal Works Tomitrurtiun ami#
Application is hereby made for a Permit to Construct ( ) or Repair (----)'an Individual Sewage Disposal
System at:
Location Address or Lot No.
........CPC f1iwG._.._4�1 ..._ ....... ....................
- ... . ddr
Owner -----.•-_-.--Address
a UYV$.......�CC fh/ft`-7N........... ... ........... . ..•---............__._.... ....------•.....•..........................
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms............................................Ex ansion Attic Garbage Grinder
a g— P ( ) g (. )
p,, Other—Type of Building ............................ No. of persons............................ Showers Cafeteria ( )
Otherfixtures ........................................................... ......-......-•--•-----....----------•-•---••-•----.........•---..._..._---•--
W.
Design Flow............................................gallons per person,`�'er day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons , Length.............'..,Width._..! ......... Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No, Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.............................................................. -•-•-••---- Date........................................
aTest Pit No. I................minutes,per inch Depth of Test Pit..................... Depth to ground water........................
Lz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
9 •--••-••-•---•-•••-••---------------•••--•-•••••-•-••••.............-•--•-...........----••--••-----.........................................................
ODescription of Soil.........................-----------------•--•------•-•-•.-•-------•••--••-.....---•---------------•---------•---....------------------•-----............_............•-
x
U --••-•-•••--•---••-••-•••-••-•--•-••.•...-•-•--.........-•--•-••-•-•-••----•--••-•--...-•-.....-••----•-•--•---•-......•.._..-•••-•-••-•----•••-•••••-•-•--••---•••••-•••-•-----•----•-••-•-._..._..•---
VW --------
Nature of Repa* s.o^r Alterations—Answer when plicabl __ - ----------------;��'!''e...M A?4f'X1®e1�_ a .._..
1� !` ��..--°i� --/.C¢.c� _ i� /1?_..✓_ onl dSC ' ....
Agreement: t_
The undersigned agrees to install the aforedescribed Individual 'Sewage Disposal System.in accordance with
the provisions of iITLL 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in '.
operation until a Certificate of Compliance has e i sued by the board of health. 3,
ed _.. -_--. ---...••..---•-•.................................... ......
ication Approv d By••••-•-•-• ... .....'. •. .... ... ------•----- .� .................. }
1' ---•-•--•--•-•-•------••-•-•-••-•-•--•-----•----... ......-•------
Date for the following reasons:__________________.::..:_........
i Date
PermitNo.:...... -------.......... --------- Issued----•-......•---------------•-••--••••-................
Date
i
Nam... (p �� �. Fims......���do...._
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
/ . .N............._..OF.......... *`
Appliration fear Eliipuiittl Works Tnnitrnr#ion f rrutit
Application is hereby made for a Permit to Construct ( ) or Repair (✓) an Individual Sewage Disposal
System at
ti/ a g..
= 14y--L'ocation-Address or Lot No.
--- ---••------------------------•--•--L.0 -•------••- --.•-----------------------•----------'.-. ....--•--.....................................
Owner .............................................
Address
Installer Address
U Type > ( ) ize.Lot...
......................... feet
U w B ng ding.No. of Bedrooms__________________-----•-••--------•--------Expansion Attic S`V Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers
� YP g -----•--•-•----------•------ P ( ) — Cafeteria ( )
dOther fixtures .--•------•-•-•------•-•-•-•--------------------------..---•--------•-----------•------------••---------..........-•----........_..---•-----..._..._..
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------------------_ Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by•••--•-••••••••-••••-•--••..............•---.....---•------•--•......_.. Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0-4
L14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+ ---•------- - ---------------------------•----------- -------
..-------------
•--------------..... ------------
---------
•----------
O Description of Soil......................••--------------------------••----•--------•----•---•-------•------------•-•----•-------••---....----------------............----•--•-•----.-----
x
W
U Nature of Repai s or Alterations—Answer when pIicabl 9 .. � '0 sN e�f�
Agreement: C tfrlw6G i''r S'yc�..•,
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
p until a Certificate of Compliance has l sued by the;board of health.
operation un h ,
,�._-s—igne ----• .. •-----•....... . ............................•... ........
M D tLl
anon Approv d By........_
Date
Application Disapproved for the following reasons:..............................................................................................................
.......................12<.................................................................... :::.....---•-----------•----•-----------------------------------------•--------------------.......--••-
/ Date
PermitNo........... SGi ......... -_. Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
_ BOARD OF _HEALTH
!... ................OF..........I I- 0 ��..................
(9rdifirtt#r ,orf fl omplianr-,
THIS IS TOCERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (✓<
by-------------------------A'Q.jYA...... S,�C t!!t .................................................=.........................................................................
install
at .erg ' !' ..... 'd9z►! '/_ _.. 'wt -=----------------------------------------------------------------------
has been installAd in accordance with the provisions of TITLE 5 of The State Sanitary Code as gescribed in the
application for Disposal Works Construction Permit No... t �� --- dated....� " �L �(--------------------
THE ISSUANCE OF THIS. CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT THE
SYSTEM WILL FU T N SATISFACTORY.
DATE......: -- ----------------------------- Inspector -.........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................. �"�+?"''�.......O F........ � T tG..........................'"
No.�...�"� jF$E....... ,�
�i��gs�tl u . � �frnr�iun �.ernti#
Permission is hereby granted------ ---- ......... .......
to Construct ( ) or Repair ( an}ndividual ewage Disposal System
at No.---•--•-•--l.1a .. �.. --.... ..
Street
as shown on the application for Disposal Works Construction Permit NoA...�a Dated_. L46
r
r .
•------- .---- �.. ---------------------------------
® Board of Health
DATE .........................
f
FORM 1255 A.
- ULKIN,'INC., BOSTON
LOCA.T10 J SEWAGE PERMIT NO.
L-A �tm�lf4Z
� .
VILLAGE
�n
INSTA LER'S NA pE, & ADDRESS
1 -5
\i UI LDyE R OR 01\�\KER
DATE PER-MIT ISS-UED
DATE COKPLIANCE ISSUED
���
, L.3 71Z I Fizs.2s,.... .....
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
............ . Town.............OF................B. krn-stable------------------...............--------
Appliratiun fur lliipuual Workii Taira rnr#ivia trua t
Application is hereby made for a Permit to Construct (X ) or Repair ( ) an Individual Sewage Disposal
System at:
Lot # .. �A...... 1.�ram` .. ,........ Hya1�z�7 s.a
.......• _. ....--------•.............................
Locati Address or Lot No.
Ca ricorn Realt Trust 6 '
----.........--......_..........••---.........�' ......----7---5..F.11mo_lath..R aad.---H.Yannis..............
... .. ner _ I. .................................Address
Installer Address
QType of Building Size Lot.....................:......Sq. feet
U Dwelling—No. of Bedrooms--------3....................... .Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building r.ZMCh------- No. of persons............................ Showers (2 ) — Cafeteria'( )
a' Other fixtures ----------------------------------
W Design Flow..............55........................ per person per day. Total daily flow.................33Q...................gallons.
ft
WSeptic Tank—Liquid ca.pacity1000_gallons Length.8-�_6��._._ Width._—'..lV� Diameter................ Depth.-5�_�......
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.....1............. Diameter.....(z'.._....... Depth below inlet.......&'........ Total leaching area.....266....sq. ft.
Z Other Distribution box ( ) DosinE tank ( )
'-' Percolation Test Results Performed by.. 1WY'ed9e_- ............. Date...... 1_-25,--$1............
aTest Pit No. lK2,.Q...minutes per inch Depth of Test Pit--------].2'__.. Depth to ground water.none -eneounterd-
(i, Test Pit No. 2..N/A.....minutes per inch Depth of Test Pit...N/A......... Depth to ground water.N/A.. e
x •----------------------•----......---------...................................------------------------------------........------....-----------.......--••--
ODescription of Soil..........D-.'-----...2--'-------------loam...&...to-pso•i•1----------------------•------•-•----------------•-----------••-•--•------.--------.----
2'- 1Q medium--.y-ellaw...s .....................................
U 10` - 12 ' med. white sand traces of grayellno-water-__at 12 '
--------------------- --------------------------- --------- -------------------- ------
U Nature 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 TMH,;;,. 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 y the board of health.
Signed__. .. f - ----- .............
--- ----- . .... 7P. P,= .........
-
� � Date
Application Approved By...... ............................. ..`.
.................
Vate
Application Disapproved for the following reasons:-------•-------------------•---•-----------------------•------------------------...............................
-----------------------------•---•----------•-------------------•--------•------.............-•----------------------------.-------- - ---- ---------------------
Date
PermitNo......................................................... Issued.......................................................
Date
_a
+�' t
72 Nan.. ---I --3 t FEs... 3.. ..:..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.................To--im.............OF...............Barnstable--------•----••-----._....---.-.-_-----.--
Appliration for UiipnsFal lgorkfi Tonstrnrtion prrmff
Application is hereby made for a Permit to Construct (g ) or Repair ( ) an Individual Sewage Disposal
System at:
c, t : 1 f� - --- 8,...DQA..
Lo t .j Iry c� ..
.............. _ ...----....... ..........--•--•------- --------...............................
Location-Address or Lot No.
. apricorn..Rea tY...'�' u t 7_f ...Ealmlouth._Aaadr---Hy:annia..............
C
w Steve Lebel Owner Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms--------3--------•------------------------Expansion Attic ( ) Garbage Grinder ( )
P4 Other—Type of Building ranch.............. No. of persons............................ Showers (2 ) — Cafeteria ( )
Q' Other fixtures ------------------------•----•-•--
W Design Flow..............5.5............._._....._..gallons per person per day. Total daily flow__•----•-------_33CI...................gallons.
WSeptic Tank—Liquid capacity1000.gallons Length-$............ Width. '1o'. Diameter................ Depth.# 11._..
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------I------------- Diameter.....6.1.._._..... Depth below inlet.......6......... Total leaching area.....�.....sq. ft.
Z Other Distribution box ( ) Dosinfi tank ( )
Percolation Test Results Performed by.._..ldredg•Q... ngine.ering............. Date.....Jl-25.=81............
64
Test Pit No. 1-<2...Q...minutes per inch Depth of Test Pit........12-'.... Depth to ground waters ne_-_enepunter..
(i Test Pit No. 2..N/A----.-minutes per inch Depth of Test Pit..N/-k--_______ Depth to ground water_N/A.............. C1
GG
p a
Description of Soil..........Q-------'---�--............�.4atT1--&..t0 e0L�.�.--•-------....----------------------------------------------•---------._....----•-----
x 2 1— 1: # me-di�3IT1_..y.Qnom..4gld---•-
W Ifs i " med. white sancV traces---°f_.-�rayellno---water--at 12 '
---------------------------------------------------------------------•-•--- - - ---
U Nature 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 TT I,;a. 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.
Signed.�4. .... .71
,Date
Application Approved By------_ s-- -_ 'vim-•- ------------------------------ ---.l _ L..................
Date
Application Disapproved for the following reasons-------------•---•---------------.....------------------•---••-•-----------------•------------------------•-•----
-•-----•--........--•------•-•-----------------------------------------•--•--•--..........-•---------------•-----------....••-----•--------•----•••---------------••-----•----------•-•-----•••...-•--•-
Date
PermitNo--------------------------------------------------------- Issued-----------------------•-----•--•---............._.....
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................. own............OF............Barnstable..............................-.........
Trrifirtt of f�rrntlittnrr
TH.j,S IS OLeF e�IFY, That the Individual Sewage Disposal System constructed � ) or Repairedtev ( )
by----------------------e......---•D-------------------•----- ..........-- •-----.....------------------•-----.....-•-•------ ...............------------•--•-•---•-•----•--•---------
Installer
at Lot j .......... �'�/' 4=1 ' - ----.................................... lClnis 'ls
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No------ Z._.__...... dated_________________________________________••-•
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...----•--•-•-----...-•-•-•-•----�/Z?=// ..................... Inspector......�-_&.............................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town ....................OF........Ba1^2lstable 5.•..=r
FEE.......................
Elifivosal luorkil Tonotrurtion rrmit
Permission is.hereby granted = ....../�'i�tn. .1d...........................................................................
to Cons uct (X ) or Repair ( ) an Individual Sewage Disposal System
Flo # Lt .�.f !.. , !1 1� -----.----- xannis, '
at No.----•-•------•......:.......:.. .---..............
Street
as shown on the application for Disposal Works Construction Permit No.................... Dated..........................................
.....................................................
Board of Health
DATE....................................... ...............
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS