HomeMy WebLinkAbout0266 STRAIGHTWAY - Health 266 Straightway
Hyannis
A=267 127
J � ,
No. !' / Fee cJ
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppliCation for Misposal 6pste tt Construction 3dermit
Application for a Permit to Construct( ) Repair(�l Upgrade( ) Abandon( ) ❑Complete System [Individual Components
Location Address or Lot No. ,2(p(o 5-rAA((;.-&{T(yA,� JAN( Owner's Name,Address,and Tel.No.
30t}t l JetA<AASTW%4
Assessor'sMap/Parcel p��pgZng S ?(p 5_r 16U4TUU6 t4v,4-il w
Installer's Name,Address,and Tel.No.-%Z-C f 7-1-27C 77 Designer's Name,Address,and Tel.No.
`.4Qc�wcAG eG1Ji7sw5-rsi�%.45�0 - NI.-
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided 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) RGj?( At 9 1 kO)C
'1 09T u— i N u:;-r 23-�N Sal,-_ _TAP C.
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 Healt .
S' a Date 7 -30 �-
Application Approved by Date a
Application Disapproved by Date
for the following reasons
Permit No. vie' ^ ,�� Date Issued a f
Rom--•� �+ Jr�. °,��'€,.:. �,�.,,:.,.- �3.,��„.� ,,�;;;� _J�., ,.W i� tn5_
•"\..-�v. 5in'^�7..3 Nf ."..^ !,l°I'4'+` ."'FWD "Y. "'l� f•" 'Ni .'C`"�."PfS+"� .., AMThy^•. JM+y. '�l„ µ�"Tr�Y'+�f 9„' �, A'' •�
a.. 1
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OFBARNSTABLE, MASSACHUSETTS Yes
ftpticatlon for Misposal Opstrm Construction 3permit
Application for a Permit to Construct( ) Repair 0 6 Upgrade( ) Abandon( ) ❑Complete System [Individual Components
Location Address or Lot No. ,?(OG 5-rQAIQ47 WX, k%q Owner's Name,Address,and Tel.No.
a6tim ),-tto.ApTNy
Assessor'sMap/Parcel p2(pgrAg S ;16(o SlAmewrwAS1 I"EMPMfS
Installer's Name,Address,and Tel.No. .(477`—2Sr-T7 Designer's Name,Address,and Tel.No.
cq Q�we 4 G t�N��72�►�r s�s Cv IA-
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
r;
4
Nature'of Repairs or Alterations(Answer when applicable) �� � . P,C&
tJS T�4 L to Lk:--r mbx;: 6,) 5�-Zr i c `TAN C
Date last inspected:
. Agreement:
"r 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 o Health.
S'gned Date
Application Approved by Date
Application,Disapproved b -
,. pp Y. .Date .
for the"following reasons - t
Permit No. r Q f '"" 1`�Cj Date Issued 41 �d
-- -- - -= - --- -- ---------------------- --- -- --- -- ------------ - ------------- --- -----•------- - - - -= -!
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(X) Upgraded( )
Abandoned( )by _QA Pr t o LTA C_ FNT i�7RNV<ec
at- 57 r?r4(r M)A y Fl YotN Xu 1< has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No>/% lD5dated
)30
Installer C—w((mC" Designer N1A
#bedrooms Approved design flow gpd
The issuance of this , rr�mi hall not be construed as a guarantee that the syste �willfuncti a de ig ed.
Date t< `ry' /(,) Inspector
-. - _ - - - - - ------------------------- --------- -------------,------------- ------------=-_--_----------
1 No. } � Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
Misposal 6pstrm Construction 3permit
Permission is hereby granted to Construct( ) Repair(x) Upgrade( ) Abandon( )
System located at 2(,& 5'T1ZA1 Q(4 j(c,k\/ t4 Yk rJ 0 ( S
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:Construction ust be co le e ell within three years of the date of this s permit.
DateQ Ll Approved b`y
ct
��i.
Town of Barnstable
Regulatory Services
t
Thomas F. Geiler, Director
NAM ' Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
February 7; 2008
Lucimeire J. Hoffinan
266 Straightway
Hyannis, MA 02601
r
NOTICE TO ABATE VIOLATIONS OF TOWN OF BARNSTABLE CODE
The property owned by you, located at 266 Straightway, Hyannis was inspected on
February 5, 2008 by Town of Barnstable Health Inspector Donald Desmarais RS because
of a complaint.
The following violation of the Town of Barnstable Board Code was observed:
$353-1 Responsibilities of Owners: Garbage and rubbish observed in the back yard not
within proper receptacles. Overflowing trash cans in front yard. Numerous carpets on
ground in back yard.
You are directed to remove the garbage and rubbish from your property and
dispose of it properly within 7 days of your receipt of this notice.
You may request a hearing before the Board of Health if written petition requesting same
is received within ten(10) days after the date the order is served.
Failure to comply with an order will result in a fine of$100.00. Each day's failure to comply
with an order shall constitute a separate violation.
PER ORDER OF THE BOARD.OF HEALTH
Thomas A. McKean, R.S., CHO
Director of Public Health
Town of Barnstable
Q:\Order letters\Refuse\911 pitchers way,Hyannis 2.doc
Citizen Web Request Page 1 of 1
NEER=
,. ....., .. .
Citizen Request Management
Request ID: 21560 Created: 1/31/2008 9:31:00 AM
Status: Assigned To Staff Assigned To: Desmarais, Donald
Health Office
21
Anonymous: Yes Category:
Article X - Food
Unsanitary Conditions
E.C. Date: . _ _ .2/5/2008
Created By: Wadlington, Ellen Citations:
Health Office
r Time Worked: 0 Response Time: 0
Request Location: PANERA BREADS
790 IYANNOUGH ROAD/RTE132
Hyannis, Ma 02601
Parcel Number: Map: 311 Block: 092 Lot: 000
Request:
Eating at Panera and noticed a worker cleaning overhead vents which were over the food
counter and the food was not covered.
Request Work History:
http://issgl2/IntemalWRS/WRequestPrintPub.aspx?ID=21560 1/31/2008
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CA
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UVIA ON�� ---I OF i.=-.SS s�-�JS =!-S
ExEc=FIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
'v 5
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
]PART A
CERTIFICATION
.Property Address:
add d�i5''
i
(3wner's Name: ..,
Owner's Address: Q :.:
ro YO(O c�Date of Inspection: �Z g -
Name of Inspector• (please print) rn ie��e,l
C
x -b
Company Name: A-a4.✓af-1c. tv%sPtv+toA.S �,;
Mailing Address: ul
Telephone Number: A—DIR 3r Y` bR c
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
M training and experience in the proper fimcrion and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system_
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Bate:
The system inspector-shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable,and the approving
authority.
Notes and Comments
****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.
TitW5 Inspection Form 6/150-000 page 1
Page 2 of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMMN'TS
SUBSURFACE SEWAGE DISPOSAE'SYSTEM INSPECTION FORM
- PART A
CER'I MCAT ION(continued)
Property Address:
Owner-
Date of Inspection:t_l$,k 1-0<
Inspection Summary: Check A,E,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I have-not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below:
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined N ND in
(Y, , the for the followin
g statements.If please
lease
explain.
The septic tank is metal and over 20 years old*or the septic tank(vv er metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is' ent.System will pass inspection if the
existing tank is replaced with a complying septic tank as approved b e Board of Health.
*A metal septic tank will pass inspection if it is structurally soon ,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break High static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or ven distribution box,System will pass inspection if(with-
approval of Board of Health):
brok ipe(sj ape z
ob is removed
butioti boot is L—eeled or replaced
ND explain:
The system required p ing more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if(with app val of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Palle 31 of I I
OFFICIAL,INSPEC T I
S VOLUNTARY
SUrRSURFFACE SEWA E DISPOSASYSTEM INS CTION FOR ASSESSMENTS
PART A
CERTIFICATION(continued)
Property Address: fp '0.
Owner:
Date of inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require fiarther evaluation by the Board of Health in oZdete - temis failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 3t the
system is not functioning in a manner which will protect public health, fety 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 land or a salt marsh
2. System will fail unless the Board of Health(and ublic Water Supplier,if any)determines that the
system is functioning in a manner that protects th public health,safety and environment:
_ The system Has a septic tank and soil orption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surf a water supply,
— The system has a septic tank an AS and the SAS is within a Zone i of a public water supply.
The system has a septic d SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic and SAS and the SAS is less than 100 feet but 50 feet or more f om a
private water supply well".Method used to determine distance
"This system passes i he well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile is compounds indicates that the well is free from pollution from that facility and
the presence of onia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria ggered.A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of I 1
OFFICIAL INSPECTION FOR--NOT FOR VOLUNTARY_ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM x.
PART A.
CERTIFICATION(continued)
Property Address: �
Owner:
Date of Inspection o
,rrID. System Failure Criteria applicable to all systems:
You must indicate"yes„or"no"to each of the following for g l inspections:
Yes No
— Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invest.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
® Required pumping more than 4 times in the last year NO_ T 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 l 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 1DEP certified laboratory,for area bacteria and volatile organic.compazads
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal:to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
Health to determine what will be necessary to correct the failure:
E. Large Systems:
To be considered a large system the system must serve.a facility with gn flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no-to each of the f(offlU t
(The following criteria apply to large systems in addition a criteria above)
yes 1p
— _ the system is within 400 feet of a s e drinking water supply
— — the system is within 200 feet _a tributary to a surface drinking water supply
— — the system is located in nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone II of a public er supply well
If you have answered"y 'to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D e the large system has failed.The owner or operator of any large system considered a
significant threat er Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The syst owner should contact the appropriate regional office of the Department.
4
gage 5 of 11
OFFICIAL INSPECTION FORM—NOT.FOR VOL
_UN'I'ARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHEC MIST
Property Address: cs--f 4-- t"
Owner:
Date of Inspection (,-Lai p l—
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
A _ 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?
�f Qa Have large volumes of water been introduced to the system recently or as part ofthis inspection?
ilf a 1 Were as built plans of the system obtained and examined?(If they were not available note as NIA)
_ — Was the facility or dwelling inspected for signs of sewage back up
_ Was the site inspected for signs of break out?
4 _ 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
l_ Was the facility owner(and occupants if different from owner)provided with information on the proper
ien�nce of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
Atj X 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 cir ce
is unacceptable)[310 CUR 15.302(3)(b)]
5
Page 6 of
F t
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENT
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner: '1 ,,,,� I,, - , —
Date of Inspection: 4{TD6OS�
RESIDENTIAL FLOW CONDITIONS
Number of bedrooms(design): Number of bedrooms(actual): _
DESIGN flow based on 3I0 CMR 15.203(for example: 110 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no): AV
Is laundry on a separate sewage system(yes or no). [if yes separate inspection required)
Laundry system inspected es or no):
Seasonal use:(yes or noj:-�6
Water meter readings,if a fable(last 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy:ztng�Y—
COMMERCIAL'INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): o�
Basis of design flow(seats/persons/sq ):
Grease trap present(yes-or no):
Industrial waste holding tank nt(yes or no):
Non-sanitary waste disc ed to the Title 5 system(yes or no):_
Water meter readings,' available:
East date of occup y/use:
OTHER(de ribe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection es or no
If yes,volume pumped:!gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
- Single cesspool
—Overflow cesspool
_Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained front system owner)
—Tight tank —Attach a copy of the DEP approval
—Other(describe)-.
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no): A)C2
6
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSaMENTS
SUBSUR#ACE SEWAGE DISPOSAL SYSTEM INSPECTION FORD
PART G
SYSTEM INFORMATION(continued)
Property Address 166 Sfrau
f� _ dlt�tu S
Owner: 'Dot--oL4(k 4C4+ )
Date of Inspection: p
BUILDING SEWER(locate on site plan) .
Depth below grade.. 2 R it
Materials of construction:_cast iron A 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANKX (locate on site plan)
Depth below grade: t 9't'
Material of construction: concrete metal fiberglass_polyethylene
—other(explain) —'
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no :_(atta
certificate) ch a copy of
Dimensions: Cot Cc,
Mudge depth: Q "
Distance from top of slft
Vdge to bottom of outlet tee or baffle:
Scum thickness: f - �
Distance from lop of scam to top of outlet tee or bafite.-
Distance from bottom of scum to bottom of outlet tee orbaffle: 1 7"
How were dimensions determined: /w e—,t surtaO
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of Ieakage,�c.): [ to� � �
� T ACC
GREASE TRAP:_(locate on site plan)
Depth Wow grade--
Material of construction:____concrete LaI fiberglass(explain): Polyethylene_other
Dimensions:
Scum thickness:
Distance from top of scum to p of outlet tee or baffle:
Distance from bottom of sc to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumpi recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet' vert,evidence of leakage,etc..):
7
i?age$of i l
OFFICIAL INSPECTION FOR
M—NOT I+'®I2 VOLU
NTARY ASSESSMENT'S
SUBSURFACE �SE AGE DISPOSAL
SYSTEM INSPECTION Ft)RiVI
PART C
,�/ SYSTEM INFORMATION(continued)
Property Address: a� c�Try
Owner:
Date of Inspecdon•
TIGHT or MOLDING TANK: (tank must be pumped a of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete meta fiberglass_polyethylene other(explain):
Dimensions:
capacity: tallo
Design Flow: a ons/day
Alarm present(yes or no):
Alarm level: Alarm ' working order(yes or no):
Date of last pumping
Comments(condition of arm and float switches,etc.):
DISTRIBUTION BOX: pC (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: eyey
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.):
t e .
PUMP CHAMBER: te )Pumps in working Alarms in workingComments(note cber,,condition of pumps and appurtenances,etc.):
Page 9 of
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSNIEN�VTS
SIBSUI&ACE SE*AOE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFOI'.MAT'ION(continued)
Property Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number
leaching chambers,number.
leaching gaIleries,.number:
teaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovativelaltemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,a-�eot-
4�
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' ow(yes OF no):
Comments(note Condit' n 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 condi on of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
71
h
1
Wage lO of 11
OFEICIAI,INSPECTIO)S FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: �/Yi.� M
Owner: ak#Ak�
Date of Inspection: U.12(jo.)'
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply eaters the building.
V
�n
Page 1 I of I 1
OFFICIAL INSPECTION FOR. --NOTFOR VQLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
]PropertjAddress:
�tY
®caner: LIt
UA.7_
Bate of inspection:
SITE EXAM
Slope 0
Surface water 00
Check cellar
Shallow wells iW
Estimated depth to ground water-ay feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground wajer elev Lion:
$ Z ks �.lC ticr h� CPA o if
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ASSESSOR'S MAP NO.
L66ATIDN POT- -77 WOSEWAGE PERMIT NO.
A
r
� Y° LLAGE
I N S T A LLER'S NAME i ADDRESS
i LC i L rcos o sT.
to
S UILDE OR OWMER I
DATE PERMIT ISSUED
D AT E C 0 M P L I A N C E ISSUED
i
Cb
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..............................OF.......................................---------......................................_..
Appliration for �i a 1 r �ark� C� a� r r i,an amit
Application is h, eby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: a2 o,
C. .... �
-
...... XN;_�
... �........... - j . --...
*11 Odress w= or Lot No
GILo.ation
..... ..... . --- ........ ......... ..--`---------............-•--• --..............•.................................-.-......
-•----
wne ddess
nsta Address
V Type of Building Size Lot... a.G � Sq. feet `-
Dwelling—No. of Bedrooms ................................Expansion Attic ( ) Garbage Grinder ( )
'4 Other—Type of Building ._ .... No. of persons............................ Showers — Cafeteria
a Other fixtures -------------------------------------- -
w Design Flow...............................�j__....gallons per person per day. Total daily flow---- .31:�.........._......._..........gallons.
WSeptic Tank—Liquid capacity ir?5 4A.gallons Length _._ Width _`_. Diameter...... Depth..3..'
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.........../-------- Diameter......./a_'.... Depth below inlet....... Total leaching area..A 11-....sq. ft.
Z Other Distribution-box (x ) Dosing tank ( )
Percolation Test Results Performed by...dE.L/._�'.ao__'L:_.._�--_.._, ....................... ---
2___.._... Depth to ground water--------
Test Pit No. 2......... ...minutes,.per inch Depth of Test Pit-----/.2....... Depth to ground water--- ........
P4 -•••-----------------------------------------------------------••------..............__...-••••-••--........................................................
0 Description of
Soilx ......--- /v ---•---------------------------------------------------
. / ...
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 TITL% 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate oCompl, ce has been issued by the board of health.
igned ��Application Approved By.._ •------• . . _._. .. •... �--�. __
D toe
Application Disapproved for the following reasons:............ .?. _ . ._..... ..........................................................
----------------------------•----•----.....--•--•------------------...........--------••-•...------ --..........••-•-•------------------•--••---•---•-•--•---•--......------.....-•-••---••--
Date
PermitNo......................................................... Issued........................................................- --
Date
r
No................_....... Fss............._............
_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...... ............... . .-----.....OF....................
Appliratiun for %pugal Ularks Tonutrur#inn "trutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individu4 .ewage Di s 1
System at:
................_...-•---...................-----------...------..............-----........_._... .............................................. -- - .........__......._......_..
Location-Address or Lot No.
................................................................
Address
••--•....• ..................... �•....................................... ...•---•---..............................•........
nstaller Address
UType of Building' Size Lot.... ..`...�`..-=...Sq. feet
4`
.-I Dwelling—No. of Bedrooms........3................................Expansion Attic ( ) ;. Garbage Grinder'( )
e of Building a Other—T YP g --------•----•-------------- No. of persons............................ Showers ( ) — Cafeteria
d Other fixtures .
W Design. Flow..•............................S:S.....gallons per person per day. Total daily flow....3 .............................gallons.
WSeptic Tank—Liquid capacity,�S'L`.gallons Length... Width..-S_�`.... Diameter-------...... Depth...s
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area.
................... ft.
3 Seepage Pit No.........../......... Diameter......./� Depth below inlet....3:'__.-... Total leaching area...-Oe4'-...sq. ft.
Other Distribution box Dosing tank
Percolation Test Results Performed b .... .........-=�''��^' ................. Date.... Z6`�r6
..Test Pit No. I...............minutes per inch Depth of Test Pit......-.-;_-__ Depth to ground water... --.
_�44 Test Pit No. 2.........•�...minutes per inch Depth of Test Pit......%.2....... Depth to ground water..--//:-�F 7.......
P4 ------------------------------- -----------------------••-•---....-•-•••.....••
Description of Soil......... .......!v>._..,Sv�s /,V' C o�.?S.�.x ...................... .................. ........................................................
--
----------- ----------------------------------------------------------•-••......--•-- ------------------------------------•----------...-•-------•------•-......•.........
U Nature of Repairs or Alterations—Answer when applicable.........................................................:.....................................
s
.... -•-----•-•--•-••----------•-•••------•-------•------••••---------------------••---•••••••-...I..---•----•---•••------....--•---•---•---•--•... ....................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITM4 5 of the State Sanitary Code—.The undersigned further agrees not to place the system in
operation until a Certificate of Comph nce has been issued by the board of health.
gned.......... ----•--•....... ..........
�
Application Approved By.....----- J..
e/B
dip ate
e
Application Disapproved for the following reasons:.. :_�:. --- '" .....................-----•-- -----------------•-----•-•.
.....................•.............._...••--.......•---•-•-•-...--•---•----•••--•...........-----••-'-•-'•---••-••-•-------•----•---••---••------------•--••------•--•-----•--•-• ......................
Date
PermitNo........................................................ Issued------------------- ...............................
Date
*z.Y THE COMMONWEALTH OF MASSACHUSETTS
r BOARD OF HEALTH
.............�...................... .OF. �. . � ,
.................. .... ..........
(9rdif irab of Tnntilittnrr
THIS IS TO CERTIFY, hat Individual Sewage Disposal System constructed ( or Repaired ( )
by...... � .. •-•-----------------•---------_--------------•-----•-•--• ...
t)� Installer
at.................. _.-.... - r_ ''�*:... a C, '� (r•i nit fiS' 1�1k S
has been installed in accordance with the provisions of TITLE j descri_of The State Sanitary Code as_ in the
application for Disposal Works Construction Permit No..........�...--._._.........��.. dated.............. 2. ..........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARA TEE THAT THE
SYSTEM WILL FU/NCTAON
' ATISFACTORY.
7
I ector....._
- -•••--•---•-. .••. •.... .....................•--........DATE.-•-•-•--••-•....... THE y COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.......... �a
No........................ FEE.......
lhsvvAa Workg.9onatruatutt orrutit
Permissi n s hereby granted... ..................... '`-�''
-----•----•----------------------------------•--•-----•-•----------------.---
to Construct ) or Repair ( ndivi. al Sewage Disposal System
at No................................... }...-- ..11�`. '.... >r tree + U• 1
as shown on the application for Disposal Works Construction Permit No.............. . - teed t � --
" S� _ Dated-------=� _L� �:�........ '..':.
Board ea
DAT
E v ��
FORM 1255 A. M. SULKIN, INC., BOSTON
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Upper Cape Engineering
P.O. BOX 616, EAST SANDWICH, MASSACHUSETTS 02537 (617) 362-6281
Oct 5, 1986
Board of Health
Town of Barnstable
Hyannis, Mass.
Dear Sir ;
We have caused to inspect sewage system #86-515 for
Paul Antiposti , located at lot 79 8traightway,Centerville
and installed by Ellis Bros to conform with the plan
submitted by All Cape Engineering Co. The septic tank as
installed is at right angles_ to the house instead of
parallel as dipicted on the plan submitted. The distance
from the tank to the house conforms to Title V.
Thank Y u
hn Jacobi
TOWN OF BARNSTABLE
LOCA11ON- xky&S SEWAGE #
VILi AGE L A a ,A ASSESSOR'S MAP & LOT ' O�S
AME&PHONE NO. rnr.—_-r1e� � Sag1'.38 S=764�
SEPTIC TANK CAPACITY DOO l
LEACHING FACILITY: (type) �. (size) G tc
NO. OF BEDROOMS 3. r
B�9ER-0R OWNER 1 1'
,, /�L Ic 1"k "—D A vlJ0.v%-e—aL-)
PERMIT DATE: DATE: I O S
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility ,(If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(1f any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
a�g -o9s
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
rct;�
266 STRAIGHTWAY t~
Property Address
ALTISOURCE
Owner Owner's Name
information is
required for every HYANNIS MA 02601 01/23/2018 Y
page. City/Town State Zip Code Date of Inspection Sr:"
F.ea
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 NEIL JACKSON
use the return Name of Inspector
key.
J &P ENGINEERING SERVICES
kACompany Name
30 MOUNTAIN VIEW DRIVE
Company Address
BELCHERTOWN MA 01007
Citylrown State Zip Code
(413)896-6607 S13579
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evalu tion by the Local Approving Authority
01/23/2018
In etoor s Sig/D )
Date
The systemr shall submit a copy of this inspection report to the Approving Authority(Board
of Health orthin 30 days of completing this inspection. If the system has a design flow of
10,000 gpdr, 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
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owner's Name
information is required for every HYANNIS MA 02601 01/23/2018
page. Cityfrown 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:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owners Name
information is required for every HYANNIS MA 02601 01/23/2018
page. Cityfrown Sate t 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owner's Name
information is HYANNIS MA 02601 01/23/2018
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fall 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
IG 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 %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
266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owner's Name
information is required for every HYANNIS MA 02601 01/23/2018
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
for fecal coliform bacteria indicates absent and the presence
laboratory, o
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-
Y P 9 tY 9
❑ ® 10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owner's Name
information is required for every HYANNIS MA 02601 01/23/2018
page. Cityfrown 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
i f he baffles or tees material of construction
Inspected for the condition o t ,
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): 3 Number of bedrooms(actual): 6
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owner's Name
information is HYANNIS MA 02601 01/23/2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
SAS NOT DESIGNED FOR 6 BEDROOMS; DESIGNED FOR 3 BEDROOMS.
0
Number of current residents:
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
ins if available last 2 ears usage d : PUBLIC
Water meter read ( p ))
9 ( Y 9 9
Detail:
DWELLING UNOCCUPIED FOR EXTENDED PERIOD AT TIME OF INSPECTION.
Sump pump? ❑ Yes ® No
>3 MONTHS
Last date of occupancy: Date
Commercial/industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
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
M 266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owner's Name
information is HYANNIS MA 02601 01/23/2018
required for every
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: UNKNOWN
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ 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.
M ❑ 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
266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owner's Name
information is HYANNIS MA 02601 01/23/2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
APPROXIMATELY 30 YEARS, TITLE 5 INSPECTION AT BOARD OF HEALTH.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2.33'
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: >10'feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
JOINTS AND VENTING GOOD, NO SIGNS OF LEAKAGE.
Septic Tank(locate on site plan):
2' DEEP WITH 1' RISER ON
Depth below grade: OUTLET COVER
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: 10.5'X 5'X 4'
1 .
Sludge depth:
t5ins.doc•rev.6116 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
266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owner's Name
information is HYANNIS MA 02601 01/23/2018
required for every
page. Cityrrown 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
29"
j lit
thickness
51'
Distance from top of scum to top of outlet tee or baffle
i
Distance from bottom of scum to bottom of outlet tee or baffle
1711
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.):
STRUCTURAL INTEGRITY GOOD, LEVELS GOOD, INLET AND OUTLET BAFFLES GOOD, NO
SIGNS OF LEAKAGE. RECOMMEND PUMPING EVERY 2-3 YEARS IN FUTURE DEPENDING ON
USAGE.
I
9
i
i
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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owner's Name
information is required for every HYANNIS MA 02601 01/23/2018
page. Citylrown 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.):
I
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:p ty 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
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owner's Name
information is HYANNIS MA 02601 01/23/2018
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
STRUCTURAL INTEGRITY FAIR, LEVELS GOOD, FEW SOLIDS CARRYOVER, NO SIGNS OF
LEAKAGE, 26" DEEP.
3
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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 117
I Commonwealth of Massachusetts
Title 5 Official Inspection Form
9 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owner's Name
information is required for every HYANNIS MA 02601 01/23/2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: ONE
❑ 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.):
NO SIGNS OF HYDRAULIC FAILURE, SOIL DRY, NO SIGNS OF BREAK-OUT,VEGETATION
GOOD, NO SIGNS OF PONDING. 6 X 6 PRECAST LEACH PIT WITH 2"SLUDGE AT BOTTOM,
NO LIQUID, STAINING 15" FROM BOTTOM.
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.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
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owner's Name
information is required for every HYANNIS MA 02601 01/23/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owner's Name
information is required for every HYANNIS MA 02601 01/23/2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below /UoT' tv S f AA4,
❑ drawing attached separately
Lt C A 3s•Y
Q
L9>3
o�
I.
3
�1 i P
I
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
266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner Owner's Name
information is required for every HYANNIS MA 02601 01/23/2018
page. CitylTown 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: >10'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
I
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 DATABASE INDICATES GROUNDWATER GREATER THAN 20 FEET..
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
v '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
266 STRAIGHTWAY
Property Address
ALTISOURCE
Owner
Owners Name
information is HYANNIS MA 02601 01/23/2018
required for every
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