HomeMy WebLinkAbout0825 WEST MAIN STREET UNIT CAPT WINSLOW UNIT 1 - HYANNIS CONDOS 825-WES"I'MAIN-S'I'IE T- Sea Captain
Hyannis
825 West Main Street
Sea Captains Condo
A249
,
�a
G
Commonwealth of Massachusetts
Title 5 Official "Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v 825 West Main Street- units 1-6
Property Address
Sea Captain's Condo Association'
Owner. Owner's Name
information is required for every Hyannis MA 02601 8/11/14
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer, I G
use only the tab 1. Inspector. I
key to move your (J
cursor-do not James Ford
use the return Name of Inspector
key.
lab Company Name �.
P.O. Box 49
Company Address
=ram Osterville MA 02655
City/Town State Zip Code
508-862-9400 S12482
Telephone Number License Number
A
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 Furthe aluat;ion by the Local Approving Authority
8/13/14
Inspec s Signature Date
The s m inspector shall submit a copy of this inspection report to the Approving Authority(Board
of He t or DEP)within 3z: 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 r6jonal office of the DEP. The original should be sent to the system owner
and copies sent to the buy,--r,'if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
I V l� ��
lSins•3/13 Title 5 Offi is I ection Form:Subsurfa Sevkg Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal.System Form - Not for Voluntary Assessments
s
825 West Main Street- units 1-6_
Property Address
Sea Captain's Condo Association'
Owner Owner's Name
information is Hyannis is MA 02601 8/11/14
required for every y
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check 'A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or i,n.310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
t , ..
i
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 ankd over 20 years old` or the septic tank (whether metal or not) is structurally
unsound, exhibits substantpl:infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank.is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
t
t�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
825 West Main Street-units 1 t6
Property Address "
1
Sea Captain's Condo Association
Owner Owners Name
information is
required for every Hyannis MA 02601 8/11/14
page. City/Town
State Zip Code Date of Inspection
B. Certification (cont.)a
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System ConditionallyPasses (cont.):
Q 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 El ❑ ND (Explain below):
't .
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
l
G
❑ 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)ar'e'replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
4
{
i
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
Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
825 West Main Street- units 1-6
Property Address
Sea Captain's Condo Association:
Owner Owners Name 1
information is t
required for every Hyannis MA _ 02601 8/11/14
page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.);
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment':
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a s.'eptic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
n
t
**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:
a
j:
t
C ,
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"'or"No"to each of the following for all inspections:
Yes No "1
❑ ® 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
El ® Staticli'uid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 'l2 day flow
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official-Inspection Form
Subsurface Sewage Disposal!iS:ystem Form - Not for Voluntary Assessments
825 West Main Street- units 1-6;
Property Address
Sea Captain's Condo Associations
Owner Owners Name
information is
required for every Hyannis MA 02601 8/11/14
page. City/Town State Zip Code, Date of Inspection
B. Certification (cont.)j
Yes No .
l,1
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
V.
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary.to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system.passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
i�. :.
❑ ® The system is a cesspool serving a facility With a design flow of 2000gpd-
10,000gpd.
❑ ® The y*stem 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
neces'�ary 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.
i .
Yes No i.
❑ ❑ the s ,r�tem is within 400 feet of a surface drinking water supply
t .
❑ ❑ 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=iIWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"J. 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 3;1'0 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
(Sins•3/13 i ` Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Y '•
I'
Commonwealth of Massochusetts
Title 5 Official. Inspection Form
Subsurface Sewage Disposal:'$ystem Form - Not for Voluntary Assessments
a
r` 825 West Main Street- units 1-6
Property Address
Sea Captain's Condo Association-
Owner Owners Name
information is 1
required for every Hyannis MA 02601 8/11/14
page. CitylTown ;, 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:
Y.
Yes No
® ❑ Pumping'information was provided by the owner, occupant, or Board of Health
j
I; '
❑ ® 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 laroje volumes of water been introduced to the system recently or as part of
this ins'Fection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
availadle.note as N/A)
❑ ® Was the facility or dwelling inspected for signs of sewage back up?
i
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
a;
® ❑ 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,
dimensn)ns, depth of liquid, depth of sludge and depth of scum?
Was th,e:facility owner(and occupants if different from owner) provided with
❑ ® informati.or on the proper maintenance of subsurface sewage disposal systems?
The si e.and location of the Soil Absorption System (SAS) on the site has
been determined based on:
r
® ❑ Existing information. For example, a plan at the Board of Health.
lil
® ❑ 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)]
,l
D. System Information
Residential Flow Conditions'
R! :
r n/a n/a
Number of bedrooms (design): Number of bedrooms (actual):
t � .
DESIGN flow based on 316`''MR 15.203 (for example: 110 gpd x#of bedrooms): n/a
,.r
(Sins•3/13 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
II
i
i..
Commonwealth of Mass�c`husetts
u Title 5 Official!°•Inspection Form
Subsurface Sewage Disposa SIystem Form - Not for Voluntary Assessments
825 West Main Street- units 1-6
Property Address
Sea Captain's Condo Associatio�i'
Owner Owners Name I,
information is
required for every Hyannis MA 02601 8/11/14
page. CitylTown State Zip Code Date of Inspection
D. System Informatiotr ''
Description: i
i.
s .
l;1
Number of current residents!` '
unknown
Does residence have a garbage grinder?
❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection
information in this report.) ! ❑ Yes ® No
Laundry system inspected? ,';
❑ Yes ® No
Seasonal use?
i. ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
unavailable .
YYI A
f�f '
Sump pump? ❑ Yes ® No
Last date of occupancy: currently
Date
Commercial/Industrial FloW Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Canons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
L.
Grease trap present? h El 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:
.. f
Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
r
1
II
Commonwealth of Massachusetts
Title 5 Official 'Inspection Form
Subsurface Sewage Disposal' ystem Form - Not for Voluntary Assessments
w.,a 825 West Main Street- units 1-6
Property Address
Sea Captain's Condo Association
Owner Owners Name
information is Hyannis ti MA _ 02601 8/11/14
required for every y � '
page. City/Town !' '. State Zip Code Date of Inspection
D. System Information (cont.)
t;
Last date of occupancy/use;; Date
f'
Other(describe below):
i
:i
i" General Information
Pumping Records:
k
Source of information: pumped yearly
Y'
Was system pumped as pat:t6f 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 cess'6ol
4 ;•
❑ Overflow ce?spool
❑ Privy
E,
❑ 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
inspectionf the 1/A system by system operator under contract
10
❑ Tight tank.'Attach a copy of the DEP approval.
❑ Other(describe):
is
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System.•Page 8 of 17
i - i
;l
Commonwealth of Massachusetts
Title 5 Officiat Inspection Form
Subsurface Sewage Disposal;; ystem Form - Not for Voluntary Assessments
°�M v 825 West Main Street- units 1-6,
Property Address q
Sea Captain's Condo AssociatiO
Owner Owners Name
information is
required for every Hyannis MA 02601 8/11/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all comp,o.rents, date installed (if known) and source of information:
installed on unknown date
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
i
Depth below grade:
feet
Material of construction:
❑ cast iron ® 40'l'VC ❑ other(explain):
Distance from private water"subply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on siteplan):
Depth below grade: 20
feet
Material of construction: '.
® concrete ❑ m;Ptal ❑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: t 2000 gal.
Sludge depth: 2
15ins-3/13 t• Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
l� '
Commonwealth of Massachusetts
4 Title 5 Official .Inspection Form
Subsurface Sewage Disposal;;System Form - Not for Voluntary Assessments
4
,M a 825 West Main Street- units 1-6
Property Address
Sea Captain's Condo Association
Owner Owners Name
information is MA 02601 8/11/14 Hyannis required for every H y ;l r
page. City[Town 4' State Zip Code Date of Inspection
D. System Information. (cont.)
.l
Septic Tank (cont.)
I n.
r,
Distance from top of sludge' to bottom of outlet tee or baffle
29
o
Scum thickness 3
Ij ;'.i 6
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 15
How were dimensions dete'mihed? measure
6 '
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tees were present. The inl,et,cover was 4"below. There were no sign of leakage.
i!I
i '
h
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction: j
E
❑ 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
(Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
f
Commonwealth of Mass'chusetts
Title 5 Official 'Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
825 West Main Street- units 1-6: .
Property Address
Sea Captain's Condo Associatibn
Owner Owners Name
information is
required for every Hyannis MA 02601 8/11/14
page. City/Town i; State Zip Code Date of Inspection
D. System Informatiofl:(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.):
r
i
i
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
z .
Material of construction:
❑ concrete ❑ metal' ❑fiberglass ❑ polyethylene
❑ other(explain):
N/a
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: El Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping:
Date
Comments (condition of alam,and float switches, etc.):
t,
.i
i�
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
l5ins•3/13 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
825 West Main Street- units 1-6
Property Address
Sea Captain's Condo Association
Owner Owners Name [
information is
required for every Hyannis MA 02601 8/11/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if preserit_must be opened) (locate on site plan):
Depth of liquid level above outlet invert n/a
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.):
ii
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.):
a.
* 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):
[i
If SAS not located, explain W`hy:
15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official-Inspection Form
Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments
825 West Main Street-units 1-6
Property Address
Sea Captain's Condo Association
Owner Owners Name
information is
required for every Hyannis MA 02601 8/11/14
page. City/Town State Zip Code Date of Inspection
D. System Informatican (cont.)
Type:
5 i
® leaching pits'. number: 4 - 1000 gal.
❑ leaching choepbers number:
ii
❑ 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.):
There were different levels of water in each pit. There was no sign of failure. Steel covers were to
grade ,
I.
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 .
t .
Depth of scum layer i
Dimensions of cesspool
Materials of construction
i
Indication of groundwater inflow ❑ Yes ❑ No
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 OfficialAnspection Form
Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments
825 West Main Street- units 1-6:
Property Address
Sea Captain's Condo Association
Owner Owners Name
information is
required for every Hyannis MA 02601 8/11/14
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.): t
C`
Privy(locate on site plan): r
Materials of construction:
Dimensions
Depth of solids
i
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/a
i
f
1 .
i!1
i .
U.
i
i
i -
t
(Sins 3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
a
C
1
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°,M a 825 West Main Street-units 126. !
Property Address
Sea Captain's Condo Association
Owner Owners Name
information is
required for every Hyannis MA 02601 8/11/14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
iq
O
I'
{
o
O
O
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Officia'I Inspection Form
Subsurface Sewage Disposal;System Form - Not for Voluntary Assessments
l;
°r 825 West Main Street- units 1-6
Property Address
Sea Captain's Condo Association
Owner Owner's Name
information is
required for every Hyannis MA 02601 8/11/14
page. City/Town State Zip Code Date of Inspection
D. System Information(cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
i
Estimated depth to high ground water: 25'
feet
Please indicate all method ':osed 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:
Using topo and water contours maps
❑ Checked with Kcal excavators, installers - (attach documentation)
6
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
;i
see above
R '
t
Before filing this Inspecti®n Report, please see Report Completeness Checklist on next page.
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
,
I,.
s+ Commonwealth of Massachusetts
Title 5 Officied . Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^A A,•'"t 825 West Main Street- units 1-6&
Property Address
Sea Captain's Condo Association
Owner Owner's Name
information is required for every Hyannis MA 02601 8/11/14
_
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A,';B,.C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
1
it
. . i
n .
C '
1
l `
c
i
ISins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
O-3 /
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 1
,M 855 West Main St. Hyannis, MA "Fishermans Village" System 1 -131 # f = l GR,4,�
Property Address sC
Fishermans Village U n 1— 1 Z- ��
Owner Owner's Name
information is Hyannis, MA 02601 10-29-10
required for y
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
P���e��� S�
When filling out
forms on the g slcoe0✓LS k1A- c,'^
computer, use 1. Inspector: I
only the tab key
to move your Darrell Stone
cursor-do not Name of Inspector r.�,{,
use the return '- fl
key. Cape Cod Septic Inspection
Company Name
� D
PO Box 1466
Company Address
Harwich MA 02645
renon Cityrrown State Zip Code
508-240-2500 S14995
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. 1 am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
=r ❑ Nee F her Evaluation by th L cal Approving Authority.
LU
cc
En 10-29-10
Ins ectors Signature Date
c�
,,,_ t Th` pstem inspector shall submit a copy of this inspection report to the Approving Authority (Board
c�� of RgAlth or DEP)within 30 days of completing this inspection. If the system is a shared system or
O
hag design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
o c;= re alto 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. V
l I
D
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
t5ins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
855 West Main St. Hyannis, MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owner's Name
information is required for Hyannis, MA 02601 10-29-10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 855 West Main St. Hyannis, MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owners Name
information is required for Hyannis, MA 02601 10-29-10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
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•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
855 West Main St. Hyannis, MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owner's Name
information is required for Hyannis, MA 02601 10-29-10
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for 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:
Systems:
D) System Failure Criteria Applicable to All S y
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•09/08 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
855 West Main St. Hyannis,.MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owner's Name
information is Hyannis, MA 02601 10-29-10
required for y
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
1 0,000g pd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El ❑ the system is located in a nitrogen sensitive area(interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 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 855 West Main St. Hyannis MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owner's Name
information is required for H annis, MA 02601 10-29-10
Y
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Condo Complex
11
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection,required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage(gpd)): 2089.04 gpd
9 � Y 9
Detail
2009-668,000 gallons
2008-857,000 gallons
Sump pump? ❑ Yes ® No
10-2010
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•09/08 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
855 West Main St. Hyannis, MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owner's Name
information is required for Hyannis, MA 02601 10-29-10
every page. City/Town 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: Discount Septic Pumping (12-2009)tank# 1
Unknown tank#2
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.
❑ Other(describe):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 855 West Main St. Hyannis MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owner's Name
information is required for Hyannis, MA 02601 10-29-10
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:
1973 Both tanks, 2007 D-box and SAS
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: Tank#1 41" Tank#2 43"
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.):
Both tanks have two inlets each having one cast iron and one SCH 40
All inlets in apparent good condition
Septic Tank(locate on site plan):
31" 33"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
2 -3,000 tanks
Dimensions:
Tank#1 - Tank#2
Sludge depth: 13" - 24"
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
4 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
855 West Main St. Hyannis, MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owner's Name
information is required for Hyannis, MA 02601 10-29-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 49 - 38"
Scum thickness 3" - 1"
Distance from top of scum to top of outlet tee or baffle
5" - 6"
Distance from bottom of scum to bottom of outlet tee or baffle 16" - 18"
How were dimensions determined? Sludge Judge
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#1
Both covers to grade under walkway Normal liquid level No sign of leakage SCH 40 outlet tee
Recommended next maintenance pumping within 1.5 years
Recommended maintenance pumping every 2-3 years
Tank#2
Grade to inlet cover 6" Outlet to grade Normal liquid level No sign of leakage SCH 40 outlet tee
Recommended next maintenance pumping within 1.5 years
Recommended maintenance pumping every 2-3 years
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
r--
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
855 West Main St. Hyannis, MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owner's Name
information is required for Hyannis, MA 02601 10-29-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
855 West Main St. Hyannis, MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owner's Name
information is required for Hyannis, MA 02601 10-29-10
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
H-20 D-65 Grade to box 54" Cover to grade Good condition 4 Outlets with speed levelers
Normal liquid level No sign of leakage Scum removed No sign of failure
II
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
855 West Main St. Hyannis, MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owner's Name
information is required for Hyannis, MA 02601 10-29-10
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 44
❑ 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.):
44 Infiltrators, in 4 rows of 11
No sign of hydraulic failure
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
r,
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
855 West Main St. Hyannis, MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owner's Name
information is
required for Hyannis, MA 02601 10-29-10
every 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
855 West Main St. Hyannis, MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owner's Name
information is required for Hyannis, MA 02601 10-29-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
TOLe
t5ins 09/08
Title 5 Official p
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
855 West Main St. Hyannis, MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owner's Name
information is required for Hyannis, MA 02601 10-29-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
>5
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: 2007
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
Plan on file
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Elevations from design plan
Bottom of SAS ELV. 49.0
Bottom of Test hole ELV. 44.0 NWE
Separation >5'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
855 West Main St. Hyannis MA "Fishermans Village" System 1
Property Address
Fishermans Village
Owner Owner's Name
information is required for Hyannis, MA 02601 10-29-10
every page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09l08
Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
J_
s-
t i
.J
` I
.-....... - -
J
1
i
,u n
o z7,
I �
0
,p COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
U9
JAN 0 6 ZGG3
TOWN O B NSTABLE
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 825 West Main Street, Unit I
Hyannis, MA 02601
Owner's Name: Sea Captains Condos
Owner's Address:
Date of Inspection: November 18, 2002
Name of Inspector:(Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map:249
Osterville,MA 02655-0049 Parcel. 035
Telephone Number: (508) 862-9400
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
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
Needs rther Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: November 25, 2002
The system inspector shall subm' a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
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. `
Title 5 Inspection Form 6/15/2000 page 1
i
Page 2 of 11 • •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main Street, Unit I
Hyannis,MA
Owner: Sea Captains Condos
Date of Inspection: November 18 2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND),in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11 • •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main Street, Unit 1 '
Hvannis, MA
Owner: Sea Captains Condos
Date of Inspection: November 18, 2002
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require fi►rther evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(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 I 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
f
Page 4 of 11 • •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main Street, Unit 1
Hyannis,M4
Owner: Sea Captains Condos
Date of Inspection: November 18, 2002
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone H of a public water supply well
If you have answered`yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11 • , •
J
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 825 West Main Street, Unit 1
Hyannis, R4
Owner: Sea Captains Condos
Date of Inspection: November 18, 2002
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS,located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No _
✓ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)].
5
f
Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 825 West Main Street, Unit 1
Hyannis, MA
Owner: Sea Captains Condos
Date of Inspection: November 18, 2002
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a
Number of current residents: n/a
Does residence have a garbage grinder(yes or no): n/a
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMIVIERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):.
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: System pumped after inspection-per mana_aement
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
•Page 7 of 1 I • •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Unit I
Hyannis, AM
Owner: Sea Captains Condos
Date of Inspection: November 18, 2002
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: Approx. 24"
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): (attach a copy of
certificate)
Dimensions: 2000 gal. (Approx.)
Sludge depth: 6"
Distance from top of sludge to bottom of outlet tee or baffle: 27"
Scum thickness: 15"+
Distance from top of scum to top of outlet tee or baffle: S"
Distance from bottom of scum to bottom of outlet tee or baffle: 3"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
No inlet tee was present An outlet tee was present. The liquid level was even with the outlet invert. Recommend pumping every
year for maintenance The cover was approximately 4"below grade.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11 •
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Unit 1
Hyannis, MA
Owner: Sea Captains Condos
Date of Inspection: November 18, 2002
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was level No solids were present.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
I
Page 9 of 11 • 0
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Unit 1
Hyannis, MA
Owner: Sea Captains Condos
Date of Inspection: November 18, 2002
SOIL ABSORPTION SYSTEM(SAS): ✓, (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 4-6'x 6'(1000 ga1J
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.):
One pit 04)was full. A newer pit 05)was dry. Another pit 06)was 314 full. The other pit 07)was full. All covers were to
grade The bottom to grade was approximately 11'.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
Page 10 of 11 •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Unit 1
Hyannis, AM
Owner: Sea Captains Condos
Date of Inspection: November 18, 2002
Map:249
Parcel.035
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
\A g
e
a ay a(o , y
3 13 38'
S" 3�o la0
10
' Page I 1 of I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Unit 1
Hyannis, MA
Owner: Sea Captains Condos
Date of Inspection: November 18, 2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25' +/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom of the leach pit to grade was approximately 11' Using the Barnstable topographic map and the Cape Cod
Commission water contours map the maps were showing approximately 25'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report.
11
r
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal,;System Form -Not for Voluntary Assessments
V. .
` M 825 West Main Street
Property Address
Sea Captain Condominiums units; 7-12
Owner Owner's Name :
information is required for every Hyannis MA 02601 3/24/14
page. Cityrrown State Zip Code Date of Inspection
1
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.
r
Important:When A. General Informationfilling out forms �I
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not
James Ford
use the return Name of Inspector
key. i
r� Company Name
P.O. Box 49
1.
Company Address
I Osterville MA 02655
»� ,; ::
City/Town 1,;s State Zip Code .
508-862-9400 S12482
Telephone Number License Number
r,
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 Furthe valua,ton by the Local Approving Authority
3/24/14
s
Insp c is Signature I Date
silbmit a copy of this inspection report to the Approving Authority(Board The tern inspector shali
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000`gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report.only describes conditions at the time of inspection and under the conditions of use
at that time.This inspecticiii does not address.how the system will perform in the future under
the same or different conditiuns of use.
5/1
Subsual5ins 3/13 Title 5 Ovv ce
I
Sewage Disposal System-Page 1 of 17
r
I
4
ii
Commonwealth of Massachusetts
Title 5 Official :inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
825 West Main Street
Property Address
Sea Captain Condominiums units 7-12
Owner Owner's Name +'
information is required for every Hyannis MA 02601 3/24/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
I>.
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CM:R 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, wi11 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 an, .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 pbss inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating thafl,the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
i
r f-
(Sins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I!
Commonwealth of Massachusetts
Title 5 OfficWlnspection Form
Subsurface Sewage DisposalSystem Form -Not for Voluntary Assessments
y'�M a • 825 West Main Street
Property Address
Sea Captain Condominiums units`-7-12
Owner Owner's Name
information is +
required for every Hyannis MA 02601 3/24/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)«i
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
Ei �;
B) System ConditionallyfPasses(cont.):
❑ Observation of sewage;baekup or break out or high static water level in the distribution box due
to broken or obstructedi:pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with bpproval of Board of Health):
H r.
i.
.i
❑ broken pipes) re'replaced .. ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box l is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
i
Y
I,
f'
Ifi
tl '
i f
❑ 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)Alt replaced ❑ Y ❑ N ❑ ND (Explain below):
Ih�r.
❑ obstruction is re'mbved ❑ Y ❑ N ❑ ND (Explain below):
r.
C) Further Evaluation isiRequired 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)irotect 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 systipm is not functioning in a manner which will protect public health,
safety and the environment:
i.
❑ 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
'r
t5ins•3113 ,;, Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
i;9
C i
i i r
Commonwealth of Massachusetts
W Title 5 Official rispection Form
Subsurface Sewage Disposal system Form -Not for Voluntary Assessments
a 825 West Main Street
Property Address
Sea Captain Condominiums units! 7-12
Owner Owners Name
information is required for every Hyannis MA 02601 3/24/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:,
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water,supply or tributary to a surface water supply.
ElThe system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply. f,
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
91
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.
t
3. Other: ; _.
;f
li
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" qr"No to each of the following for all inspections:
Yes No
❑ ® Backup®f sewage into facility or system component due to overloaded or
cloggd SAS or cesspool
El ® Dischdrge or ponding of effluent to the surface of the ground or surface waters
due tp;:an overloaded or clogged SAS or cesspool
❑ ® StaticIiquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
El ® Liquid,;depth in cesspool is less than 6" below invert or available volume is less
than 1%day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
i
I
qi
Commonwealth of Mass"` usetts
W Title 5 Official,. inspection Form
Subsurface Sewage Disposal S ys
tem Form -Not for Voluntary Assessments
825 West Main_ Street
Property Address y;
Sea Captain Condominiums units` 7-12
Owner Owners Name
information is required for every Hyannis MA 02601 3/24/14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No ? '
s
❑ ® Requited pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any py rf on of the SAS, cesspool or privy is below high ground water elevation.
❑ Z Any pd-rtion of cesspool or privy is within 100 feet of a surface water supply or
tribut f ito 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
systerh passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
Q
❑ ® The O'stem is a cesspool serving a facility with a design flow of 2000gpd-
10,OOP.gpd.
El ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails.The
system,:owner should contact the Board of Health to determine what will be
neces' ry to correct the failure.
E) Large Systems: To be considrered a large system the system must serve a facility with a
design flow of 10,000 gpd'' o115,000 gpd.
For large systems, you mint iq;,dicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the sys,t&m 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
i.
If you have answered "yes";,o any question in Section E the system is considered a significant threat,
or answered"yes" in Sectiop.D, above the large system has failed.The owner or operator of any large
system considered a signifant threat under Section E or failed under Section D shall upgrade the
system in accordance with �,Q CMR 15.304.The system owner should contact the appropriate
regional office of the DepartmLnt.
l5ins 3/13 4. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
I
a ;
f :.
Commonwealth of Mass'chusetts
Title 5 Officia inspection Form
Subsurface Sewage Disposal: ystem Form-Not for Voluntary Assessments
i;
825 West Main Street
Property Address
Sea Captain Condominiums ur its. 7-12
Owner Owner's Name t
information is required for every Hyannis MA 02601 3/24/14
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumpi.r"g information was provided by the owner, occupant, or Board of Health
�i
❑ ® Were ajqyof the system components pumped out in the previous two weeks?
® ❑ Has thd;s�stem 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
availatale 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 aI'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?
El ® Was the facility owner(and occupants if different from owner)provided with
information on the proper maintenance of subsurface sewage disposal systems?
The sip.*and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existinig"'nformation. For example, a plan at the Board of Health.
® ❑ Deter mi3ned 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): 12 Number of bedrooms(actual): 12
DESIGN flow based on 310 QMR 15.203(for example: 110 gpd x#of bedrooms): 1320
:v
t5ins-3/13 ii Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
,I
,
Commonwealth of Massilch usetts
Title 5 Officia(Anspection Form
Subsurface Sewage Disposalkry stem Form Not for Voluntary Assessments
825 West Main Street
Property Address
Sea Captain Condominiums uff(ts'�7-12
Owner Owner's Name
information is
Hyannis
required for every MA 02601 3/24/14
page. Cityrrown zip Code
Date of Inspection
D. System Informati6h,.1
Description:
Number of current residents?i n/a
Does residence have a gar6 i 6ge grinder? El Y6_s E No
Is laundry on a.separate set aq' e system? (Include laundry system inspection
information in this report.) Yes No
Laundry system inspected?,:, 0 Yes No
Seasonal use?
Yes No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
unavailable
Sump pump? z 0 Yes E No
Last date of occupancy: ..currently
Date
Commercial/industrial F14'conditions:
Type of Establishment:
Design flow(based on 3100J M13 115.203):
Gallons per day(gpd)
Basis.of design,flow(seats/persons/sqft, etc.):
Grease trap present?
El Yes ❑ No
Industrial waste holding tank present?
0 Yes El No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes F No
Water meter readings, if available:
t5ins-3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
a
P
I r
�I.
Commonwealth of Massachusetts
Title 5 Official :inspection Form
Subsurface Sewage Disposal;"!System Form -Not for Voluntary.Assessments
�M 825 West Main Street
Property Address t:
Sea Captain Condominiums units 7-12
Owner Owner's Name
information is required for every Hyannis MA 02601 3/24/14
page. Cityrrown State Zip Code Date of Inspection
U.
D. System Information;(cont.)
Last date of occupancy/use:: " Date
Other(describe below):
h '
I
I
I '
General Information
Pumping Records:
Source of information: di. pumped yearly
Was system pumped as pa4 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
maintenan'WL contract(to be obtained from system owner)and a copy of latest
inspection'of the I/A system by system operator under contract
❑ Tight tank.'Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
I'.
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal'*stem Form - Not for Voluntary Assessments
• 825 West Main Street
Property Address
r
Sea Captain Condominiums unfits 7-12
Owner Owners Name x ,,
information is
required for every Hyannis MA 02601 3/24/14
page. City/Town State Zip Code Date of Inspection
D. System Information.(cont.)
Approximate age of all coml�`c'nents, date installed (if known)and source of information:
installed -unknown
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on its plan):
i
Depth below grade: feet
Material of construction:
1
❑ cast iron ® 40 VC ❑ other(explain):
Distance from private water;3tapply well or suction line: feet
Comments (on condition of points, venting, evidence of leakage, etc.):
Septic Tank(locate on site-`O12n):
Depth below grade: `` 20tt
t feet
Material of construction:
® concrete ❑ netal El fiberglass El polyethylene ❑ other(explain)
i .:
54fi ,
i 1
F ..
SiF
If tank is metal, list age:
; . years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 2000 gals.
!s
F Oi 211
Sludge depth: ,
t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
s
Commonwealth of Massachusetts.
= Title 5 Official inspection Form
Subsurface Sewage Disposal:$ stem Form - Not for Voluntary Assessments
,M 825 West Main Street '
Property Address
Sea Captain Condominiums units'7-12
Owner Owners Name
information is
required for every Hyannis ' MA 02601 3/24/14
page. City/Town State Zip Code Date of Inspection
D. System Informatio'h` cont.)
Septic Tank(cont.)
29
Distance from top of sludge':to bottom of outlet tee or baffle
Scum thickness <
Distance from top of scum to top.of outlet tee or baffle 6
Distance from bottom of scuit,to bottom of outlet tee or baffle 15
ti
How were dimensions determined? measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tees were present. The.re'was no sign of leakage.The inlet steel cover was to grade
t
i
Grease Trap (locate on site
:plan):
,f
Depth below grade: feet
Material of construction:
t:
Elconcrete El metal ❑fiberglass ❑ polyethylene ❑ other(explain):
I,:
N/a ;
Dimensions:
---Scum
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17
i
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
Subsurface Sewage Disposal'System Form -Not for Voluntary Assessments
825 West Main Street
Property Address
Sea Captain Condominiums units' 7-12
Owner Owner's Name
information is required for every Hyannis ' MA 02601 3/24/14
page. City/Town State Zip Code Date of Inspection
D. System Informatidh.(cont.)
.
Comments (on pumping re6pmmendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank.must.be pumped at time of inspection) (locate on site plan):
Depth below grade:
i
Material of construction:
❑ concrete ❑ m1ol. ❑fiberglass ❑ polyethylene ❑ other(explain):
N/a
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ElYes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
c:
.i
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
I If
l;•
i l.
Commonwealth of Massachusetts
Title 5 Official,
,Inspection Form
Subsurface Sewage Disposall,!§ystem Form - Not for Voluntary Assessments
825 West Main Street
Property Address
Sea Captain Condominiums units 7-12
Owner Owner's Name R.
information is Hy
annis MA 02601 3/24/14
required for every
page. City/Town State Zip Code Date of Inspection
D. System Informatidn' '(cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above duilet invert even
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or but of box, etc.):
The D-box was normal and'there were speed levels on the outlets. A steel cover was to grade.
'i
1
Pump Chamber(locate onsite plan):
Pumps in working order. F' El Yes El No'
Alarms in working order: ; ❑ Yes ❑ No'
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
V'�t
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:
, r
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
v Title 5 Officia ` 'Inspection Form
Subsurface Sewage Disposal i.System Form-Not for Voluntary Assessments
�r
�M 825 West Main Street
Property Address 4
Sea Captain Condominiums ur7►ts 7-12
Owner Owner's Name
information is required for every Hyannis MA 02601 3/24/14
page. City/Town State Zip Code Date of Inspection
D. System Information'"(cont.)
Type:
® leaching pits~ number:
4-6x6 1000 gal.
f
❑ leaching chambers number:
❑ leaching gall'�ries number:
❑ leaching treri*ojhes number, length:
❑ leaching fields' number, dimensions:
I•
❑ overflow cess'pbol 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.):
3 of the pits had 3'of water on the bottom.The fourth pit was dry.There was no signs of failure.They
all had steel covers to grade.
4.
i'
Cesspools (cesspool musfbe pumped as part of inspection)(locate on site plan):
Number and configuration N/a
Depth—top of liquid to inlet;invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction `
Indication of groundwater inf:'low ❑ Yes ❑ No
,I
t5ins•3/13 ! ' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage DisposalASystem Form -Not for Voluntary Assessments
fj
825 West Main Street
Property Address
Sea Captain Condominiums units 7-12
Owner Owner's Name
information is required for every Hyannis MA 02601 3/24/14
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.):
r
I •
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.):
N/a
i,
f'
y
it
}
i
I
i;
I• '
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
ji
r'
Commonwealth of Massachusetts
H v Title 5 Official Inspection Form
Subsurface Sewage Disposal-,,System Form -Not for Voluntary Assessments
f.
825 West Main Street
Property Address
Sea Captain Condominiums units 7-12
Owner Owner's Name
information is required for every Hyannis MA 02601 3/24/14
page. City/Town State Zip Code Date of Inspection
D. System Informati6h4(cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
ft:
13
t
�o
.;
0
J.
;;
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage DisposahSystem Form -Not for Voluntary Assessments
° 825 West Main Street I'
Property Address
Sea Captain Condominiums ubits. 7-12
Owner Owner's Name
information is
required for every Hyannis _ MA 02601 3/24/14
page. City/Town State Zip Code Date of Inspection
D. System Informatioo,('cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar {
❑ Shallow wells ;
Estimated depth to high grd6nd water: 20'
feet
Please indicate all methods'used to determine the high ground water elevation:
❑ Obtained from 9 stem design plans on record
If checked, date�.of,design plan reviewed: Date
❑ Observed site (;butting property/observation hole within 150 feet of SAS)
® Checked with heal Board of Health-explain:
Using topo and:water contours maps
❑ Checked with local excavators, installers-(attach documentation)
3
❑ Accessed USES database-explain:
i,
You must describe how you established the high ground water elevation:
see above.
.aF
I `
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
i
4.
e '
. ye
Commonwealth of Massachusetts
Title 5 Official, inspection Form
_ Subsurface Sewage Disposal!System Form- Not for Voluntary Assessments
,M a> 825 West Main Street '
Property Address
r'
Sea Captain Condominiums units, 7-12
Owner Owner's Name
information is !
required for every Hyannis >!• MA 02601 3/24/14
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
E Inspection Summary: AiB, C, D, or E checked
E Inspection Summary D!(System Failure Criteria Applicable to All Systems)completed
E System Information— Estimated depth to high groundwater
E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
P ,
i
`i
. , .`
I.
1
I i
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
•COMMONWEALTH OF MASSAC SETTS1Z4
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAP
PARCEL,
LOT
TITLE 5
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Sea Captains Condominiums
Property Address: 825 West Main Street, Units 7-12
Hyannis, MA 02601 q
Owner's Name: Cape Cod&Islands Property Management
Owner's Address:
c✓;
Date of Inspection: —September 13, 2004
- =z.1
Name of Inspector: (Please Print) James M. Ford - _
Company Name: James M. Ford
Mailing Address: P.O. Box 49 ?
Osterville,MA 02655-0049 cr% rn
r
Telephone Number: (508)862-9400
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
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:
1
✓ Passes
Conditionally Passes
Noe4s Further Evaluation by the Local Approving Authority
F it
Inspector's Signature: Date: September 18, 2004
The system inspector shall su it 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 lias"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.
Title 5 Inspection Form 6/15/2000 page 1
r
Page 2 of 11 •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main Street, Units 7-12
Hyannis, MA
Owner: Cape Cod&Islands Property Management
Date of Inspection: September 13, 2004
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main Street, Units 7-12
Hyannis, MA
Owner: Cape Cod&Islands Proper Management
Date of Inspection: September 13, 2004
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
s
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11 •
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main Street, Units 7-12
Hyannis, MA
Owner: Cape Cod& Islands Property Management
Date of Inspection: September 13, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.)
No (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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to-large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11 •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 825 West Main Street, Units 7-12
Hyannis, MA
Owner: Cape Cod&Islands Property Management
Date of Inspection: September 13, 2004
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓" _ Were all system components,excluding the SAS, located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of 1 I •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 825 West Main Street, Units 7-12
Hyannis, M4
Owner: Cape Cod&Islands Property Management
Date of Inspection: September 13, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a Number of bedrooms(actual): 14
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a
Number of current residents: n/a
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11 •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Units 7-12
Hyannis, MA
Owner: Cape Cod&Islands Property Management
Date of Inspection: September 13, 2004
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 20"
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): (attach a copy of
certificate)
Dimensions: 2000 gal.
Sludge depth: 5"
Distance from top of sludge to bottom of outlet tee or baffle: --
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs ofleakage Steel covers
were to grade.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 1 I •
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Units 7-12
Hyannis, MA
Owner: Cape Cod&Islands Property Mana ement
Date of Inspection: September 13, 2004
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: P-allons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D-box was level. No solids were present Speed levelers were present
PUMP CHAMBER: None locate on site plan)
( P )
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
II ,
Page 9 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 825 West Main Street, Units 7-12
Hyannis, MA
Owner: Cape Cod&Islands Property Management
Date of Inspection: September 13, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 4-6'x 6'(1000 ag l.)
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.):
Two of the pits were dry and the other two pits had Y ofliquid on the bottom. Steel covers were to grade
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Units 7-12
Hyannis, MA
Owner: Cape Cod&Islands Property Management
Date of Inspection: September 13, 2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
/� I I STu.I COvcif
U�
O
r
CC
10
Page 1 I of I 1 •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Units 7-12
Hyannis, MA
Owner: Cape Cod&Islands Property Mana ement
Date of Inspection: September 13, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20 + feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic maps and water contours maps the maps were showing approximately 20'+ to ground water
at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11 i
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
i
TITLE 5
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
•Sea Captains Condominiums
Property Address: 825 West Main Street, Units 12A-24 �I
Hyannis,K4 02601 q 1 15 .
Owner's Name: Sea Captains Condo.Association
Owner's Address:
Date of Inspection: . February 14, 2013
Name of Inspector: (Please Print) James M Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
CERTIFICATION STATEMENT i
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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: L L Date: February 25, 2013
The system inspector shall s b it a copy�fj`this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of com 'ng 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 i
****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.
Title 5 Inspection Fonn 6/15/2000 page 1
I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main Street, Units 12A-24
Hyannis,MA
Owner: Sea Captains Condo.Association
Date of Inspection: February 14, 2013
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: r
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND);in the for the following statements. If"not determined",please
explain.
r
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or Break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
I
2
r i
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main Street, Units 12A-24
Hyannis,MA
Owner: Sea Captains Condo.Association
Date of Inspection: February 14, 2013
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require furtlier'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 mariner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to'a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS.is less than 100 feet but 50 feet or more from a
private water supply well**. Method used to determine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
'i
}
3
I
s ` Page 4 of 11
{
OFFICIAL INSPECTIONT FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main'Street. Units 12A-24
Hyannis,MA
Owner: Sea Captains Condo.Association
Date of Inspection: February 14, 2013
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped—
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion.of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (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.
6
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd
You must indicate either"yes"or"no"to eachAof the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
_ the system is within 400 feet'of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
yl
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
t ,
i
i
Page 5 of 11
OFFICIAL INSPECTIONv FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 825 West Main Street, Units 12A-24
Hyannis,MA .`.
Owner: Sea Captains Condo.Association
Date of Inspection: February 14, 2013
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?
F
✓ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS,located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ Determined in the field(if,any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
i
5
v
Page 6 of 11
'i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
A
Property Address: 825 West Main'Street, Units 12A-24
Hyannis,MA
Owner: Sea Captains Condo.Association
Date of Inspection: February 14, 2013
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 24 Number of bedrooms(actual): 24
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 2640
Number of current residents: n/a
Does residence have a garbage grinder(yes or no): Some units have them-per manager
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No 'i
Water meter readings,if available(last 2 years usage(gpd)): unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied Note:Inside of condos not inspected. Information is per manager.
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): Qpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or,,no)
Non-sanitary waste discharged to the Title 5.system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped yearly
Was system pumped as part of the inspection,(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping: _
TYPE OF SYSTEM
✓ Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Originals in approximately 1974-date of newer pits unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
r
Page 7 of 1 I
s
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Units 12A-24
Hyannis,MA t
Owner: Sea Captains Condo.Association
Date of Inspection: February 14, 2613
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 24"
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): (attach a copy of
certificate)
Dimensions: 4000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outletttee or baffle: --
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: --
Distance from bottom of scum to bottom of outlet tee or baffle: --
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
An outlet tee was present. Steel covers were to grade. No sign of leakage
GREASE TRAP: None (locate on site plan)
Depth below grade:
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: '
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
7
{
1
i
i
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main'Street, Units 12A-24
Hyannis,MA
Owner: Sea Captains Condo.Association
Date of Inspection: February 14, 2013
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
1 :
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping: ,
Comments(condition of alarm and float switches,etc.):
1
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
p
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
A steel cover was to Qrade.
a ,
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber;condition of pumps and appurtenances,etc.):
f
J
8
1
r
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main 'Street. Units 12A-24
Hyannis,MA
Owner: Sea Captains Cando.Association
Date of Inspection: February 14, 2013
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number 8-6'x 6'(1000 Qal.)w/approzimately 2'stone
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.):
Some of the pits had water in them some were dry. There was no sien of failure. All steel covers were to Qrade. The bottoms to
grade were approximately 10.5'.
CESSPOOLS: None (cesspool must be ptimped 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 or no): _
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
c
1
44
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Units 12A-24
Hyannis,MA
Owner: Sea Captains Condo.Association
Date of Inspection: February 14, 2Q]3
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
All G Ovo .1 Art- To 6(,4&
c
G
a
1 F
i
6
I
10
s
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Units 12A-24
Hyannis,MA
Owner: Sea Captains Condo.Association
Date of Inspection: February 14, 2013
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans,on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health'.-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps,the maps were showing approximately 25'+to ground water at this site.
i
I
This report has been prepared onlyfor the septic system and conrporrents described herein. This septic system has beers
inspected and passed as of the date of inspection. This report is not a warranty or guarantee that the system will
finrction properly in the ftttur-e. There have been rio warranties or guarantees, either expressed, written or implied,
relating to the septic system, the inspection,this report arid/or airy components of the septic system which have not
been located and inspected
i
11
I_
r COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE.OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE S
OFFICIAL INSPECTION FORM-.NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION i
Sea Captains Condominiums
Property Address: 825 West Main.Streel Units 12A-24
Hyannis. MA 02601
Owner's,Name: Sea Captains Condo Association
Owner's Address:
Date of Inspection: December 5 2008
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
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
training and experience in.the proper function and inamicnance.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
eeds Further Evaluation by the Local Approving Authority
ails
Inspector's Signature:, Date: December 11, 2008
The system inspector shall subs it 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.
Title 5 Inspection Form . 6/15/2000 page 1 I
Page 2 of 11
r
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main Street Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo Association
Date of Inspection: December 5 2008
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:
4
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y;N,ND)in the for the'following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is iimninent. System will pass.inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance,
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board.of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I 1
OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main Street Units 12A-24
_ Hyannis. MA
Owner: Sea Captains Condo Association
Date of Inspection: December S 2008
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1, System will pass unless Board of Health.determines in accordance with 310 CMR.15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(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,perfonned at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ainmonia 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:
3
Page 4 of 11
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main Street Units.12A-24
HVannis..MA
Owner: Sea Captains Condo Association
Date of Inspection: December 5 2008
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each.of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters.due to an overloaded or
clogged SAS or cesspool
✓ Static 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
✓ 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 I of a public well:
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (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 System:
To be considered.a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The.following criteria apply to large systems in addition to the criteria above)
Yes No
_ the system is within 400 feet of.a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public'water supply well
If you have answered"yes"to any question in Section E the system.is considered a significant threat or.answered
"yes"in Section D above the-large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance.with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 825 West in Street units 12A-24
Hyannis. MA
Owner: —Sea Cadtains Condo Association
Date of Inspection: December 5 2008
Check if the followinZ have been done: You must indicate"Yes"or"no"as to each of the followin :
Yes No
✓ Pumping infonnation 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 nonnal_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 backup?
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system components, excluding the SAS,located on site?
✓ — Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems
The size and location of the Soil'Absorption System (SAS)on the site has been determined based on:
Yes No
✓ — Existing information. For example,a plan at the Board of Health.
✓ _ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
Page 6 of 11
OFFICIAL INSPECTION.FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 825 West Main Street Units 12A-24
Hyannis:MA
Owner: Sea Captains Condo Association
Date of Inspection: December S 2008
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 24 Number of bedrooms(actual): 24
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 2640
Number of current residents: n/a
Does residence have a garbage grinder(yes or no): Some units have them-per manager
Is laundry on a separate sewage system(yes or no):. No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied Note:Inside of condos not inspected. Information is per manager.
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no).
Non-sanitary waste discharged:to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe): -
GENERAL INFORMATION
Pumping Records
Source of information: pumped yearly for maintenance-per manager
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: �. gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no). (if yes,attach.previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Originals in approximately 1974 date of newer pits unknown
Were sewage odors detected.when arriving at the site(yes or no): No
6
Page 7 of 11
r:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 825 West Main Street Units 12A-24
_ Hvannis. MA
Owner: Sea Ca
vtains Condo..Association
Date of Inspection: December 5 2008
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: cast iron 40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting, evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 24"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confinned.by a Certificate of Compliance(yes or no): (attach a copy of .
ficate)
certi
Dimensions: 2500 Qal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: 6-8"
Distance from top of scum.to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: --
How were dimensions determined: Measuring stick
Comments(on pumping recominendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage; etc.):
An outlet tee was vresent. Steel covers were to zrade. Recommend pumping system annually or maintenance.
GREASE TRAP: None (locate on site plan)
)
Depth below grade:
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:
Comments(on pumping reco.rrimendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
.'e
�11
Page 8 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 825 West Main Street Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo Association
Date of Inspection: December 5 2008
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: allons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alann in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
There were 6 outlets in the D-box. No solids were vremnt. Note:In the fitture, the D-box should be replaced because the
concrete has started to deteriorate. A steel cover was to yLi ade.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarns in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 825 West Main Street Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo Association
Date of Inspection: December 5 2008
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 8- 6'x 6'(1000 Qal)w/approxiniately 2'stone
leaching chambers,number:
leaching galleries,number:
leaching trenches,number;length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name:of technology:
Commments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil
etc.): ;condition of vegetation,
There were 5 on anal 12its and 3 newer vits. .5 Pits were'/z till I was ull and 2 were dry All steel covers were to made. The
bottoms to grade were agDrorimately 10.5'.
CESSPOOLS: . None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation; etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Continents(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
9
s.,
Page 10 of 11.
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 825 West Main Streeti Units 12A-24
Hvannis. MA
Owner: ..Sea Captains Condo Association
Date of Inspection: Decentbei 5 2008
SKETCH OF SEWAGE DISPOSAL'SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where.public water supply enters the building.
t q as door �-�I
"A aI 13
Q�
L as S Ft q � a 3
� 3q 31
y �y c/o
s �o sg
0
10
t
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 825 West Main Street Units 12A-24
Hyannis, MA
Owner: _Sea Captains Condo. As
Date of Inspection: December 5 2008
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
0
Estimated depth to ground water. 25+/- feet
Please indicate(check)all methods used to'detennine the high.ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within.150 feet of SAS)
✓ Checked with local Board of Health:explain: topographic and water contours mans
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps the snaps were showing approximately 25'+to gi ound water at this site
This report has been prepared only for the septic.system and components described herein. This septic system has been
inspected and passed as of the date of inspection: This report is not a warranty or guarantee that the system will
function properly in the future. There have been no warranties or guarantees, eitherr expressed, written or implied,
relating to the septic system, the inspection, this repot andlor any components of the septic system which have not
been located and inspected.
. 11
` COMMONWEALTH OF MASSACHUSETTS
('YV1�= n �30 ( #` ft��
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
?!1 t+r
DEPARTMENT OF ENVIRONMENTAL PROTi8l"TLOt4, 13 r 2: Q
s 510---
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Sea Captains Condominiums
Property Address: 825 West Main Street, Units 12A-24
Hyannis, MA 02601
Owner's Name: Sea Captains Condo.Association
Owner's Address:
Date of Inspection: June 6, 2005 4 t
Name of Inspector: (Please Print) James M. Ford
Company Name: James M.Ford
Mailing Address: P.O.Box 49
Osterville,MA 02655-0049
Telephone Number: (508)862-9400
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
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
Need urther Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: June 12, 2005
The system inspector shaYlg
of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of nspection. 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.
Title 5 Inspection Form 6/15/2000 page 1
f
Page 2 of 11 •
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main Street, Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo.Association
Date of Inspection: June 6, 2005
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer es no or not determined Y N ND in the for the following statements. If"not determined" lease
Y ( ) g ,P
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11 •
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main Street, Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo.Association
Date of Inspection: June 6, 2005
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(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 I 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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main Street, Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo.Association
Date of Inspection: June 6, 2005
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 1 of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary.to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
f15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 825 West Main Street, Units 12A-24
Hyannis. MA
Owner: Sea Captains Condo.Association
Date of Inspection: June 6, 2005
Check if the following have been done: You must indicate"yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS,located on site?
✓ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
✓ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ Existing information. For example,a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)].
5
• •
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 825 West Main Street, Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo.Association
Date of Inspection: June 6, 2005
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 24 Number of bedrooms(actual): 24
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 2640
Number of current residents: n/a
Does residence have a garbage grinder(yes or no): Some units have them-per manager
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system.inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings,if available(last 2 years usage(gpd)): unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied Note:Inside of condos not inspected. Information is per manager.
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Unavailable
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: _gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank, distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) (if yes,attach previous inspection records,if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Originals in approximately 1974-date o newer pits unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo.Association
Date of Inspection: June 6, 2005
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 24"
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): (attach a copy of
certificate)
Dimensions: 2500 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: --
Scum thickness: 5-8"
Distance from top of scum to top of outlet tee or baffle-
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
No inlet tee was present. An outlet tee was present. Steel covers were to grade. Recommend pumping system annually or
maintenance.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
f
Page 8 of 11 0
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Units 12A-24
Hyannis. MA
Owner: Sea Captains Condo.Association
Date of Inspection: June 6, 2005
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
There were 6 outlets in the D-box. No solids were present. Note:In the future the D-box should be replaced because the
concrete has started to deteriorate. A steel cover was to grade.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main Street, Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo.Association
Date of Inspection: June 6, 2005
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 8-6'x 6'(1000 gal.)wlgpproxiniately 2'stone
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.):
There were 5 original pits and 3 newer nits. Pits#1 and#2 were full. Pit#3 had Y of liquid on the bottom Pit#4 was dry. Pit
95 had 1'ofliguid on the bottom. Pit#6 was full. Pit#7 had 3'of ILquid on the bottom Pit#8 had P ofliguid on the bottom
All steel covers were to Qrade. The bottoms to grade were approximately 10.5'
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 825 West Main Street, Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo.Association
.Date of Inspection: June_6, 2005
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
s acor �L�-------------
1°1 a
a� �3
�A
Q
� Q �
� 3q 3J
3
y 'Jy c/o
s q o S8'
�y s/ 0
0
7Ly� y7
g 5
q 3� q �
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 825 West Main Street, Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo.Association
Date of Inspection: June 6, 2005
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25+/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using Barnstable topographic and water contours maps,the naps were showing approxitnately 25'+to ground water at this site
This report has been prepared and the system inspected and passed as of the-date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed,written or implied,relating to the system, the inspection and/or this report.
11
r
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL P OTEO
RECEIVED
MAR 0 7 2002
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 825 West Main St., Units 12A-24
Hyannis, MA 02601
Owner's Name: Sea Captains Condo Association
Owner's Address: Same
Date of Inspection: February 8, 2002
Name of Inspector:(Please Print) James M. Ford
Company Name: James M. Ford Map,:249
Mailing Address: P.O. Box 49 Parcel: 03500
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
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
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
Need urther Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: February 15, 2002
The system inspector shall 4submaof 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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11 •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main St., Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo Association
Date of Inspection: February 8, 2002
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
15.363 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND) in the for the following statements. If"not determined",please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of 11 • •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main St., Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo Association
Date of Inspection: February 8, 2002
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(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 coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
f
Page 4 of 11 •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 West Main St., Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo Association
Date of Inspection: February 8, 2002
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static 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_.
Y
✓ 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 I of a public well.
✓ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
✓ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone II of a public water supply well
If you have answered`yes"to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
Page 5 of 11 • •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 825 West Main St., Units 12A-24
Hyannis, M4
Owner: Sea Captains Condo Association
Date of Inspection: February 8, 2002
Check if the following have been done: You must indicate`yes"or"no"as to each of the following:
Yes No
✓ Pumping information was provided by the owner,occupant, or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection ?
✓ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ Was the site inspected for signs of break out?
✓ Were all system components,excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered,opened, and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ Existing information. For example, a plan at the Board of Health.
✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable) [310 CMR 15.302(3)(b)J.
5
Page 6 of 11 • •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 825 West Main St., Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo Association
Date of Inspection: February 8, 2002
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 24 Number of bedrooms(actual): 24
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 2640
Number of current residents: n/a
Does residence have a garbage grinder(yes or no): Some units have them-per manager
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): 2001- 1,162,500 gals. for 3 buildings total
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied Note:Inside of condos not inspected. Information per manager.
C O MMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CN R 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped on Aug. 30101 and Feb. 16100-per treatment plant
Was system pumped as part of the inspection(yes or no): No
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓ Septic tank, distribution box, soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes,attach previous inspection records, if any)
Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Originals in approximately 1974-newer ones unknown
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11 • •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main St., Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo Association
Date of Inspection: February 8, 2002
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: Approx. 24"
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): (attach a copy of
certificate)
Dimensions: 2500 gal.
Sludge depth: 5"
Distance from top of sludge to bottom of outlet tee or baffle: --
Scum thickness: 12-15"
Distance from top of scum to top of outlet tee or baffle: --
Distance from bottom of scum to bottom of outlet tee or baffle: --
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
No inlet tee was present. The outlet tee was present. Solids were up to the top of the outlet tee. The system needs pumping The
covers were to grade.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage, etc.):
7
Page 8 of 11 . •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main St., Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo Association
Date of Inspection: February 8, 2002
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
Solids were present in the D-box. There were 6 outlets in the D-box. Recommend cleaning and pumping. The cover was to
grade.
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
8
Page 9 of I I • •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main St., Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo Association
Date of Inspection: February 8, 2002
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 8-6'x 6'(1000 gal.)with approximately 2'stone
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.): +
There were S original pits and 3 newer pits. Pit#1 was full, pit#2 had Y ofwater, pit#3 had 2'ofwater, pit#4 was dry, pit#S
had 1'of water, pit#6 was full,pit#7 was dry and pit#8 had 4'of water. The bottom of all of the pits to grade was approximately
10'6". All covers were to grade.
CESSPOOLS: None (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (locate on site plan)
x. Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
9
I
Page 10 of 11 i
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main St., Units 12A-24
Hyannis, MA
Owner: Sea Captains Condo Association
Date of Inspection: February 8, 2002
Map:249
Parcel: 03500
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
8 Door ao 6t� &`�
� 1 S8 39 02 3I roe 3 a3
3� q1
.33 �� y
b`l s q0 S S8
y
10
Page 11 of 11 • •
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 West Main St., Units 12A-24
Hyannis, AM
Owner: Sea Captains Condo Association
Date of Inspection: February 8, 2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom of the leach pits to grade was approximately 10'6". Using the Barnstable topographic map and the Cape Cod
Commission water contours map, the maps were showing approximately 25'+1-to groundwater at this site. Using the Cape Cod
Commission Technical Bulletin, the high ground water adiustment for this site(MI W 29, Zone D, 12101)was 7.0'.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
r
GrA d
/�. 0 �-I►q� Grovndw/�T� leve
aS o ,q G rovA(�WA7c r I eve I
BY STREET 9/14/2004
Perii%t#. Date .. _ Hauler Prop Owner __ ..Hse#, Sheet,_._:.
33306 20031785.1 10/15/2003 Ace Sea Captain Vil 825 West'Main Stre
33312 20031784.1 10/15/2003 Ace Sea Captain Vil 825 West Main Stre
t 33325 20031793.1 10/15/2003 Ace Sea Captain Vil 825 West Main Stre
400 988911.1 1/9/1998 A& B Canco- Sea Captain C 825 West Main Stre
424 989441.1 3/6/1998 Macomber Lebel 942 West Main Stre
425 989442.1 3/6/1998 Macomber Lebel 942 West Main Stre
831 989779.1 4/9/1998 Bortolotti Lambert 1000 West Main Stre
903 989711.1 4/14/1998 Ace Donut Works 751 West Main Stre
12611 980208.1 5/5/1998 Ace Jack's Lounge 373 West Main Stre
1264 980210.2 5/5/1998 Ace Copper Kettle 644 West Main Stre
1283 980206.2 5/6/1998 Ace Dairy Queen 14 West Main Stre
1335 980201.1 5/8/1998 Ace Hyannis Honda 830 West Main Stre
1350 980257.1 5/9/1998 Ace Hyannis Honda 830 West Main Stre
16831 980503.1 6/1/1998 Bortolotti Lambert's Fruit 1000 West Main Stre
1781 980561.1 6/9/1998 A& B Canco Golden Fountai 203 West Main Stre
1802 980614.2 6/10/1998 Ace Copper Kettle 644 West Main Stre
1848 980612.1 6/12/1998 Ace Dairy Queen 14 West Main Stre
2041 980740.1 6/25/1998 Macomber Bryant 968 West Main Stre
21241 980787.1 7/1/1998 Ace Midpoint Motel 560 West Main Stre
2232 980922.1 7/9/1998 Ace Dairy Queen 14 West Main Str'e
2259 980914.2 7/10/1998 Ace Copper Kettle 644 West Main Stre
2263 980940.1 7/10/1998 A& B Canco Trovato, Dave 474 West Main Stre-
2511 981059.1 7/23/1998 A& B Canco Paddock Resta 0 West Main Stre:
2703 981216.1 8/5/1998 Ace Copper Kettle 644 West Main Stre
2719 981271.2 8/6/1998 Ace Donut Works 751 West Main Stre
2720 981272.1 8/6/1998 Ace Dairy Queen 14 West Main Strew: ;
2721 981272.2 8/6/1998 Ace Jack's Lounge 373 West Main Stre
32241 981575.2 9/9/1998 Ace Copper Kettle 645 West Main Stre
3226 981576.2 9/9/1998 Ace Dairy Queen 14 West Main Stre
3349 981670.1 9/16/1998 Macomber Sushi by Yoshi 0 West Main Stre
3555 981837.1 9/30/1998 A& B Canco Golden Fountai 203 West Main Stre
3574 981897.1 10/1/1998 Robinson New England P 0 West Main Stre
37881 981988.2 10/16/1998 Bortolotti Baldini, Mike 530 West Main Stre
4025 982147.1 10/30/1998 Robinson II Maestro Rest 0 West Main Stre
4029 982192.1 11/2/1998 A& B Canco Home Cooking 213 West Main Stre
4220 982244.2 11/13/1998 Ace Jack's Lounge 373 West Main Stre
4236 982262.2 11/16/1998 A& B Canco Paddock Resta 0 West Main Stre
4259 982365.2 11/18/1998 Ace Dairy Queen 14 West Main Stre
4437 982443.1 12/2/1998 Bortolotti Fisherman Villa 0 West Main Stre
4438 982442.1 12/2/1998 Bortolotti Fisherman Villa 0 West Main Stre
4446 982476.1 12/3/1998 A& B Canco Sea Captains C 825 West Main Stre
4447 982475.1 12/3/1998 A& B Canco . Sea Captains.0 825 West Main-Stre
y4448 982474.1 12/3/1998 A& B Canco Sea Captains C 825 West Main Stre
4449 982473.1 12/3/1998 A& B Canco Sea Captains C . 825 West Main Stre
4574 982549.1 12/15/1998 Ace Copper Kettle 644 West Main Stre
45771 982548.2 12/15/1998 Ace Donut Works 751 West Main Stre
Page 1
Commonwealth of Massachusetts
�a Title 5 Official Inspection Fora r�'y
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r-n
855 West Main St System#2
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is
required for every Hyannis MA 02601 9-6-2018 9
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer,
use only the tab Darrell Stone
key to move your Name of Inspector
cursor-do not Cape Cod Septic Inspection
use the return Company Name
key. •
P.O. Box 1466
rag Company Address
Harwich MA 02645
City/Town State Zip Code
anua 508-240-2500 S14995
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property 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 inspection I have determined
that the system:
1. ® Passes
2. ❑ Condition ly Passes
3. ❑ Need Furt er Evaluation by t Local Approving Aut
4. ❑ Fail
j
9-7-2018
Insp or's Si a V 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
r t
Commonwealth of Massachusetts
Title 5 official Inspection form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�c /�%
855 West Main St System#2
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is required for every Hyannis MA 02601 9-6-2018
page. Cityrrown 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 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:
2) 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):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
1 855 West Main St System#2
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is required for every Hyannis - MA 02601 9-6-2018
page. Cityfrown 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 ❑ 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" Ej ND (Explain below):
3) 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.
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 health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
i r <
Commonwealth of Massachusetts
Title 5 Official Inspection Fo°rrn
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
855 West Main St System#2
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is required for every Hyannis MA 02601 9-6-2018
page. City/Town . State Zip Code Date of Inspection
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:
❑ 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.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
[I ® 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
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
Commonwealth of Massachusetts
5- Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
v 855 West Main St System#2
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is required for every Hyannis MA 02601 9-6-2018
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 Y2 day flow ,
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ ® 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.
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" or"no" to each of the following, in addition to the
questions in Section CA.
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
s t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
c Commonwealth of Massachusetts
Title 5 official Inspection Form
I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
855 West Main St System#2
`J Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is MA 02601 9-6-2018
required for every Hyannis
page. City/Town State Zip Code Date of Inspection
C. Inspection summary (cont.)
If you have answered "yes" to any question insSection 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
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. Fo`r 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)]
f5lnsp.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 Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.1
855 West Main St System#2
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is required for every YH annis MA 02601 9-6-2018
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms (design): NSA Number of bedrooms (actual): 16
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 1760
Description:
Residential condo building with 16 bedrooms
Number of current residents:
5+
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 ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
` Last date of occupancy: Current
Date
i
r
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
Commonwealth of Massachusetts
�x Title 5 Official Inspection Dorm
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
855 West Main St System#2
Property Address
p Y
Fishermans Village Condo Association
Owner Owner's Name
information is required for every Hyannis MA 02601 9-6-2018
page. City/Town State Zip Code. Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial,Flow Conditions:
Type of Establishment:
Desi n flow based on 310 CMR 15.203
g ( ) per da Gallons p y(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? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
p g
Source of information: 8-2016 Discount Septic Pumping (508) 240-2500
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t
I
• r
15insp.doc-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 16
Commonwealth of-Massachusetts °
lix Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
� 855 West Main St System#2
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is required for every Hyannis MA 02601 9-6-2018
page. Cityrrown 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:
Pre 1978
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 43 +/
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.):
Apparent good condition
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
< Commonwealth of Massachusetts
�m ,p Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
855 West Main St System#2
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is Hyannis MA 02601 9-6-2018
required for every y
page. Cityrrown State. Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank (locate on site plan):
Depth below grade: 37"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ .No
Dimensions: 3000 gallon
Sludge depth: 10"
Distance from top of sludge to bottom of outlet tee or baffle
56"
1"
Scum thickness
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
24"
How were dimensions determined? Sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grade to inlet cover 7" Outlet 8" Normal liquid level No sign of leakage
Sch 40 outlet tee
Recommended next maintenance pumping within 1 year
Recommended maintenance pumping every 2-3 years
15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
,� Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
855 West Main St System#2
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is required for every Hyannis MA 02601 9-6-2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. 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
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
855 West Main St System#2
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is required for every Hyannis MA 02601 9-6-2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Bolding Tank (cont.)
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
9. Distribution Box (if present must be opened) (locate on site plan):
011
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Grade to box 50" Cover 14" OK condition 3 outlets with speed levelers
Normal liquid level No sign of leakage Scum removed No sign of failure
15insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
�y Title 5 Official Inspection Form
' i Subsurface Sewage Disposal System Form Not for Voluntary Assessments
t (,
.............,... 855 West Main St System#2
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is required for every Hyannis MA 02601 9-6-2018
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
10. 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.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
® leaching pits number: 3
❑ 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
ISubsurface Sewage Disposal System Form - Not for Voluntary Assessments
� stem#2 855 West Main St S
,.� Y
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is required for every Hyannis MA 02601 9-6-2018
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
3 (6x6) pits with stone
Grade to pit#1 49" Cover 2" Bottom 123" Ponding 4"
Grade to pit#2 61" Cover to grade Bottom 137" Ponding 6"
Grade to pit#3 61" Cover 2" Bottom 137" Ponding 32"
No sign of hydraulic failure
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
is Title 5 Official Inspection Form
�= k} Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
855 West Main St System#2
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is Hyannis MA 02601 9-6-2018
required for every H y '
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp-doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official inspection Form
} Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M
855 West Main St System#2
u Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is required for every Hyannis MA 02601 9-6-2018
;page. Cityrrown 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
N
c
ls
I �-
f
I
I �- Ili 'l�" IO
74
15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
Title 5 official Inspection Form
�= Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
855 West Main St System#2
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is required for every Hyannis MA 02601 9-6-2018
page. Cityrrown 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: >4
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:
Previous inspection on file
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database explain:
You must describe how you established the high ground water elevation.-
Elevations from USGS database
Approx. Property ELV. 60.0-56.0
Approx. Bottom of SAS#1 ELV. 49.75 -45.75
Approx. Bottom of SAS#2 ELV. 48.59 -44.59
Approx. Bottom of SAS#3 ELV. 48.59 -44.59
Approx. GW ELV. 36.0
Adjustment 4.1' MIW-29 Zone D 8.2' November 2010
Separation >4
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts -
'1 1. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e 855 West Main St System#2
Property Address
Fishermans Village Condo Association
Owner Owner's Name
information is Hyannis MA 02601 9-6-2018
required for every y
page. Cityrrown 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. System 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
t5insp.doc•rev.7/26/201B Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Commonwealth of Massachusetts
�V ; Title 5 Official Inspection Form
9N_i ''i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
855 West Main St. System#2 Hyannis, MA
Property Address Z �oSf -P
Fishermans Village Condo Associations �- 5
Owner Owner's Name
information is Hyannis MA 02601 12-20-2010 _
required for State Zip Code Date of Inspection
every page. City/Town
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer, use 1. Inspector:
only the tab key
to move your Darrell Stone
cursor-do not Name of Inspector
use the return —i
key. Cape Cod Septic Inspection
Company Name
k PO Box 1466 ,
Company Address �
Harwich MA N "02645 r�
ierom City/Town State ^Zip Code
508-240-2500 _ S14995
Telephone Number License Number *tJ
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:
tnspector's
❑ Conditionally Passes ❑ Fails
er Evaluation by t Approving Authority
12-21-2010
e Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
' ****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Ltr
�I
Title 5 Official,Inspection Form:Subsurface Sewage Disp al System•Page 1 of 17
t5ins•09108
< Commonwealth of Massachusetts
ml — Title 5 Official Inspection Fora,
'Z
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
855 West Main St. System#2 Hyannis, MA
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is Hyannis MA _ 02601 12-20-2010
required for y State Zip Code Date of Inspection
every page. City/Town
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/ always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
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):
Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 2 of 17
t5ins•09,011
Commonwealth of Massachusetts
Title 5 official Inspection Form
i= i'� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
855 West Main St. System#2 Hyannis, MA
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is Hyannis
MA _ 02601 12-20-2010
required forState Zip Code Date of Inspection
every page. City/Town
B. Certification (cont.)
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 Boar
d 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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
t5ins•09108
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
855 West Main St. System#2 Hyannis, MA
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is Hyannis __ MA 02601 12-20-2010
required for State Zip Code Date of Inspection
every page. City/Town
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance: _ — --
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
Yes No
El ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
® Discharge or ponding of effluent to the surface of the ground or surface waters
❑
due to an overloaded or clogged SAS or cesspool
r 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 ava
El ® ilable volume is less
than '/2 day flow
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
t5ins•09/08
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
855 West Main St. System#2 Hyannis, MA
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is Hyannis __ MA 02601 12-20-2010
required for y State Zip Code Date of Inspection
every page. City[Town
B. Certification (cont.)
Yes No
El ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation..
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ® the system is within 400 feet of a surface drinking water supply
❑ ® the system is within 200 feet of a tributary to a surface drinking water supply
❑ ® 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.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
t5ins•091013
Commonwealth of Massachusetts
` 0 Title 5 Official Inspection Form
im l�' Subsurface Sewage Disposal System Form Not for Voluntary Assessments
Hyannis, MA —
855 West Main St. System#2 H y
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is Hyannis MA 02601 12-20-2010 _
required for y — State Zip Code Date of Inspection
every page. Cityrrown
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?
El ® Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑. Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
❑ ® Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
NIA 16
Number of bedrooms (design): Number of bedrooms (actual):
1760
DESIGN flow based on 310 CMR 15.203 (for example. 110 gpd x#of bedrooms):
J
Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 6 of 17
t5ins•09108
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
855 West Main St. System#2 Hyannis, MA
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is H annis MA 02601 12-20-2010
required for y State Zip Code Date of Inspection
every page. City/town
D. System Information
Description:
16 bedroom residential condo building
9
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
1562.60 GPD
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
These water records include units 1-22
2009 -499,664 gallons
2008 -641,036 gallons _ — —
Sump pump? ❑ Yes ® No
12-2010 _
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/personslsq.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:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
t5ins•09/08
Commonwealth of Massachusetts
�- � Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
855 West Main St. System#2 Hyannis, MA
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is H annis MA 02601 12-20-2010
required for y State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Last date of occupancy/use: Date.
Other(describe below):
General Information
Pumping Records:
Discount Septic Pumping 11-2009 _
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined? --
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (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):
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
t5ins•09/08
Y�
Commonwealth of Massachusetts
. _; Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
N
855 West Main St. System#2 Hyannis MA
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is Hyannis MA 02601 12-20-2010
required for y
every page. City/Town State Zip Code Date of Inspection
-
every System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Pre 1978 Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
42" _
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.):
Apparent good condition
Septic Tank(locate on site plan):
37"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years.
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑
Yes ❑ No
3000 gallon
Dimensions:
12"
Sludge depth:
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
t5ins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�a 855 West Main St. System#2 Hyannis, MA
—.—
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is Hyannis MA 02601 12-20-2010
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
54"
1/2"
Scum thickness
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
24"
Sludge judge
How were dimensions determined?
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Grade to inlet cover 7" Outlet 8" Normal liquid level No sign of leakage
SCH 40 outlet tee
Recommended next pumping within 2 years
Recommended maintenance pumping every 2-3 years
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
t5ins•09108
Commonwealth of Massachusetts
Title 5 official Inspection Form
�_%i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
z e
855 West Main St. System#2 Hyannis, MA__
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is Hyannis MA 02601 12-20-2010
required for State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain).-
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: — — Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc_):
' Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 11 of 17
t5ins•09108
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 855 West Main St. System#2 Hyannis, MA
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is required for Hyannis MA 02601 12-20-2010
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 011
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.): .
Grade to box 50" Cover 14" Good condition 3 Outlets with speed levelers
No scum Normal liquid level No sign of leakage No sign of failure
An adjustment to the speed levelers was made during the inspection so water would flow equally to
the 3 pits.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
III Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
855 West Main� St. System#2 Hyannis MA� y
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is Hyannis
MA 02601 12-20-2010
required for y
every page. CityFrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
3
❑ 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.):
3 (6x6') pits with stone.
Grade to pit#1 49" Cover 2" Bottom 123" Dry
Grade to pit#2 61" Cover to grade Bottom 137" Ponding 50"
Grade to pit#3 61" Cover 2" Bottom 137" Trace of liquid
No sign of hydraulic failure
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
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
t5ins•09/08
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1= Subsurface Sewage Disposal System Form Not for Voluntary Assessments
855 West Main St. System#2 Hyannis, MA
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is Hyannis
MA 02601 12-20-2010 _
required for -
every 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.):
Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
t5ins-09108
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
855 West Main St. System #2 Hyannis, MA
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is required for Hyannis MA 02601 12-20-2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below -
❑ drawing attached separately'
eq
Al
C �
M
A B / C-e C\
t q0 -6
2 36- 6 _ d
3 z--0 3S- 10
4 3 - ( 0- (0
5 511- O l- 0
6 2-c7- 6 6Z- 8
t5ins•09108 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
. . P;Eip Title 5 Official Inspection Form
=' ✓ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� :. 855 West Main St. System#2 Hyannis MA
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is Hyannis
MA 02601 12-20-2010
required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
>4
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:
See below
You must describe how you established the high ground water elevation:
Elevations from USGS database
Approx. Property ELV. 60.0 - 56.0
Approx. Bottom of SAS#1 ELV. 49.75 -45.75
Approx. Bottom of SAS#2 ELV. 48.59 -44.59
Approx. GW ELV. 36.0
Adjustment 4.1' MIW-29 Zone D 8.2' November 2010
Separation >4'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
t5ins•09108
Commonwealth of Massachusetts
Title 5 official Inspection Form
i' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a,.•'' 855 West Main St. System#2_ Hyannis MA
Property Address
Fishermans Village Condo Associations
Owner Owner's Name
information is Hyannis _MA 02601 12-20-2010
required for Y _
every page. CityFFown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
Z 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
i
SU FACE SEWAGE DISPOSAL SYSTEM INSFION FORM
` PART A
CERTIFICATION (continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 14
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEM PASSES: YES
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR
15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B SYSTEM CONDITIONALLY PASSES: NIA
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The
System,upon completion of the replacement or repair,as approved by the Board of Health will pass.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
_ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate
Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the
inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or
exfillration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. The system will pa
pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed
pipe(s). The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 2
SURFACE SEWAGE DISPOSAL SYSTEM INS*ION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 14
Owner: ROBERT YOO
Date of Inspection: AUGUST 12,1999
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303
(1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER.IF ANY)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND
SAFETY AND THE 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 soil absorption system and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicate;that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method
used to determine distance __(approximation not valid).
3) OTHER
revised 9/2/98 3
SUISFACE SEWAGE DISPOSAL SYSTEM INSOION FORM
PART A
u CERTIFICATION (continued)
Property Address: 825 WEST MAIN ST, HYANNIS UNIT 14
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
DJ SYSTEM FAILS. N/A
You must indicate either"Yes"or"No" to each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR
15.303. The basis for this determination is identified below. The Board of Health should be contacted to
Determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged
SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an over-
loaded 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
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 Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a
surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach
copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate
nitrogen.
E) LARGE SYSTEM FAILS: N/A
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a
significant threat to public health and safety and the environment because one or more of the following conditions exist:
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-IW PA)or
mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local
regional office of the Department for further information.
revised 9/2/98 4
SUWFACE SEWAGE DISPOSAL SYSTEM INS*. ION FORM
PART B
CHECKLIST
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 14
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and the system
Has been receiving normal flow rates during that period. Large volumes of water have not been introduced into
the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic lank was
inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid
depth of sludge,depth of Scum. The size and location of the Soil Absorption System on the site
Has been determined based on:
X Existing information. Ex. Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance is unacceptable)115.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
revised 9/2/98 5
SORFACE SEWAGE DISPOSAL SYSTEM (NOTION FORM
PART C
SYSTEM INFORMATION
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 14
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
FLOW CONDITIONS
RESIDENTIAL: CONDOS
Design flow: 220 g.p.d./bedroom for S.A.S.
Number of bedrooms(design) 2 Number of bedrooms(actual): _ 2
Total DESIGN flow
Number of current residents: N/A
Garbage grinder(yes or no): N/A
Laundry(separate system) (yes or no): N/A If yes,separate inspection required
Laundry system inspected(yes or no): N/A
Seasonal use(yes or no) N/A
Water meter readings,if available(last two(2)year usage(gpd): _
Sump Pump(yes or no): N/A
Last date of occupancy: N/A
COMMERCIAL/INDUSTRIAL: N/A
Type of establishment:
Design flow: Gpd(Based on 16.203)
Basis of design flow
Grease trap present:(yes or no):
Industrial Waste Holding Tank present:(yes or no)
Non-sanitary waste discharged to the Title 5 system:(yes or no)
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: YEARLY PUMPING
System pumped as part of inspection:(yes or no) NO
If yes,volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract.
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:
UNKNOWN
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 14
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade:
Material of construction _ cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: YES
(Locate on site plan)
Depth below grade: 2'
Material of construction X. concrete _ metal _ Fiberglass _ Polyethylene other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No) _
Dimensions:
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 45"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: _ 24"
How dimensions were determined TAPE&PLAN
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
TANK AT WORKING LEVEL,INLET NO TEE,OUTLET TEE
COVERS AT GRADE,BOTH COVERS IS'STEEL
GREASE TRAP:
(locate on site plan)
Depth below grade:
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:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
revised 9/2/98 7
SUWFACE SEWAGE DISPOSAL SYSTEM INSIOION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 14
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
TIGHT OR HOLDING TANK:N/A _ (Tank must be pumped prior to,or at time,of inspection)
(Locate on site plan)
Depth below grade:
Material of construction _ concrete _ metal _ Fiberglass Polyethylene _ other(explain)
Dimensions:
Capacity: Gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order Yes; __ No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: YES
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
D BOX IS2'X28"
ONE LINE IN
SIX LINES OUT
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No) _
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 14
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
SOIL ABSORPTION SYSTEM (SAS): YES
(locate on site plan,if possible:excavation not required,but may be approximated by non-intrusive methods)
If not located, explain:
Type:
Leaching pits,number: 6
Leaching chambers,number_
Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number,
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
SIX 1,000-GALLON PRE CAST PITS.ALL PITS HAVE 2'STEEL COVERS AT GRADE.LEACHING IS WORKING__
THREE PITS HAVE WATER,THREE PITS DRY _
DRY PITS ARE OVER FLOWS FROM OTHER PITS
CESSPOOLS: N/A
(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(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure, ,level of ponding,condition of vegetation,etc.)
PRIVY: N/A
(locate on site plan)
Materials of construction: _ _ Dimensions: _
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
revised 9/2/98 9
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMA-t-ION (continued)
Property Address: 825 WEST MAIN STRFFT, HYANNIS UNIT 14
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
SKEiCII OF SEWAGE UI PQ!3AI- SYS1t_M:
Includr Iles Io al Iq tcl Iwn prtnrnioill iefrirncrt hndnia lcs ru I,rnrhtnnilec --- ------
lnc71e III wells wilhin 100'(locale whrie supply crnnr. Inl( uiusr)
I--- —� T AA �rT
cD
revised 9/2/98 1(1
• S*RFACE SEWAGE DISPOSAL SYSTEM IN*TION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 14
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
NRCS Report name
Soil Type — — -- --— — ----
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow _— Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater 18 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
X Obtained from Design Plans on record
Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
X Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators,installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(Must be completed)
GROUND WATER DEPTH TAKEN OFF INSPECTION REPORT ON FILE AT HEALTH DEPT.
revised 9/2/98 11
1.
CoMMONWEA1,111 OF MASSACIIUSI�I"I'S
I,xl,CUT1VE OFFICE, OIL ENVIRONMENTAL A],FAIR
Ail
RETAIVI'M_IsNT O ' GNVIRONMENTAI, PROTEC"
ONEw1wrF,It.ST1i.G1"1', 13OSTON MA 02108 (617) 7.g7.-5.)) ro s
t/
iC> "tRLiTlI cOxr.
350 MAIN STREET
& WEST YARMOUTH, MA Yy VIT) 13 ,� RUiIs
ARGGO PALiI CI_:LLLICCI 508-775-2800 dh s a9 Cot saionvr
Governor
J
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Z ��
PART
CERTIFICATION
MAP249 PAR 0035-OOD
PROPERTY ADDRESS: 825 WEST MAIN STREET HYANNIS UNIT 4 ADDRESS OF OWNER:
DATE OF INSPECTION: AUGUST 12, 1999 MITCHELL GIBBS
NAME OF INSPECTOR : JAMES D. SEARS
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: A&B Canco
MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673
TELEPHONE NUMBER: (508)775-2800
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 inspection. The inspection was performed based on my training and experience in the proper
function and maintenance of on-site sewage disposal systems. The system:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS �q p
INSPECTORS SIGNATURE: DA7E:
The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heallh or DEP) within thirty(30)
days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or giealer,the inspector and the
system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original
should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority,
NOTES AND COMMENTS:
SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME
OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM.
revised 9/2/98
r` I
SU FACE SEWAGE DISPOSAL SYSTEM IN ION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 4
Owner: MITCHELL GIBBS
Date of Inspection: AUGUST 12, 1999
INSPECTION SUMMARY: Check A, B, C, or D:
Aj SYSTEM PASSES: YES
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR
15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B SYSTEM CONDITIONALLY PASSES: NIA
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The
System,upon completion of the replacement or repair,as approved by the Board of Health will pass.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate
Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the
inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank is failure is imminent. The system will pass inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. The system will pa
pass inspection if(with approval of the Board of Health),
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed
pipe(s). The system will pass inspection if(with approval of the Board of Flealth):.
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 2
I
r S RFACE SEWAGE DISPOSAL SYSTEM IN*ION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 4
Owner: MITCHELL GIBBS
Date of Inspection: AUGUST 12, 1999
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303
(1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND
SAFETY AND THE 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 soil absorption system and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that faci!ity
and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method
used to determine distance _ _ _ _(approximation not valid).
3) OTHER
r
revised 9/2/98 3
S RFACE SEWAGE DISPOSAL SYSTEM INOTION FORM
PART A
CERTIFICATION(continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 4
Owner: MITCHELL GIBBS
Date of Inspection: AUGUST 12, 1999
D) SYSTEM FAILS: N/A
You must indicate either"Yes"or"No" to each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR
15.303. The basis for this determination is identified below. The Board of Health should be contacted to
Determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged
SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an over-
loaded 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 Y 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 Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 feet of surface water supply or tributary to a
surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach
copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate
nitrogen.
E) LARGE SYSTEM FAILS: N/A
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System)and the systern is a
significant threat to public health and safety and the environment because one or more of the following conditions exist
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
mapped Zone II of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the loc;il
regional office of the Department for further information.
revised 9/2/98 4
S RFACE SEWAGE DISPOSAL SYSTEM INIOTION FORM
PART B
CHECKLIST
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 4
Owner: MITCHELL GIBBS
Date of Inspection: AUGUST 12, 1999
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and the system
has been receiving normal flow rates during that period. Large volumes of water have not been introduced into
the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was
inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid
depth of sludge,depth of scum. The size and location of the Soil Absorption.System on the site
Has been determined based on:
X Existing information.Ex. Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance is unacceptable)115.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
revised 9/2/98 5
S JRFACE SEWAGE DISPOSAL SYSTEM INAOT ION FORM
PART C
SYSTEM INFORMATION
Property Address: 825 WEST MAIN ST, HYANNIS UNIT 4
Owner: MITCHELL GIBBS
Date of Inspection: AUGUST 12, 1999
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 220 g.p.d./bedroom for S.A.S.
Number of bedrooms(design) 2 Number of bedrooms(actual): 2
Total DESIGN flow
Number of current residents: N/A
Garbage grinder(yes or no): _N/A
Laundry(separate system) (yes or no): N/A If yes,separate inspection required
Laundry system inspected(yes or no): N/A
Seasonal use(yes or no) N/A
Water meter readings,if available(last two(2)year usage(gpd):
Sump Pump(yes or no): N/A
Last date of occupancy: N/A
COMMERCIAUINDUSTRIAL: N/A
Type of establishment:
Design flow: Gpd(Based on 16.203)
Basis of design flow
Grease trap present:(yes or no):
Industrial Waste Holding Tank present:(yes or no)
Non-sanitary waste discharged to the Title 5 system:(yes or no)
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: YEARLY PUMPING
System pumped as part of inspection:(yes or no) NO__
If yes,volume pumped: _ gallons
Reason for pumping
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption.system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract.
Tight Tank_ Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed (if known)and source of information:
UNKNOWN
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 6
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 4
Owner: MITCHELL GIBBS
Date of Inspection: AUGUST 12, 1999
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade:
Material of construction _ cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: YES
(Locate on site plan)
Depth below grade: 22
Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
If tank is metal,list age _ Is age confirmed by Certificate of Compliance (Yes!No)
Dimensions: 2,500-GALLON
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 27" .
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 4"
Distance from bottom of scum to bottom of outlet tee or baffle: 21"
How dimensions were determined TAPE&PLAN
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
TANK AT WORKING LEVEL,NO INLET TEE,OUTLET TEE IN PLACE
BOTH COVERS STEEL 4"BELOW GRADE
GREASE TRAP: N/A
(locate on site plan)
Depth below grade:
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:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
revised 9/2/98 7
S URFACE SEWAGE DISPOSAL SYSTEM INOTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 4
Owner: MITCHELL GIBBS
Date of Inspection: AUGUST 12, 1999
TIGHT OR HOLDING TANK:N/A (Tank must be pumped prior to,or at time,of inspection)
(Locate on site plan)
Depth below grade:
Material of construction concrete metal Fiberglass Polyethylene other(explain)
Dimensions:
Capacity: Gallons
Design flow: gallons/day
Alarm present _
Alarm level: Alarm in working order Yes; No
Date of previous pumping: _
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: N/A
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
D BOX HAS ONE LINE IN,FOUR LINES OUT
BOX IS LEVEL AND SOLID
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No) _
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 8
Il
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 4
Owner: MITCHELL GIBBS
Date of Inspection: AUGUST 12, 1999
SOIL ABSORPTION SYSTEM (SAS):
(locate on site plan,if possible:excavation not required,but may be approximated by non-intrusive methods)
If not located, explain:
Type:
Leaching pits,number: 4
Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions: _
Overflow cesspool,number,
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
FOUR 1,000-GALLON PRE CAST PITS.ALL PITS HAVE STEEL COVERS A-f GRADE _
TWO PITS AT OULET LINE TWO DRY
CESSPOOLS: N/A
(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(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.)
PRIVY: N/A
(locate on site plan)
Materials of construction: _ Dimensions:
Depth of solids: ----
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
revised 9/2/98 9
0
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT n
Owner: MITCHELL GIBBS
Date of Inspection: AUGUST 12, 1999
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmaiks or benchmarks
locate all wells wllhln t oo'(locate where pubtic water supply comes Into house)
tt
/"�%' R O
O
O
O O
O
O
O
revised 9/2/98 10
SURFACE
SEWAGE DISPOSAL SYSTEM INOTECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 4
Owner: MITCHELL GIBBS
Date of Inspection: AUGUST 12, 1999
NRCS Report name
Soil Type -- ----- --
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate _ _ Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater 18 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
X Obtained from Design Plans on record
Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
X Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators,installers '
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(Must be completed)
GROUND WATER DEPTH TAKEN OFF INSPECTION REPORT ON FILE WITH HEALTH DEPT/
revised 9/2/98 11
- COMMONWEA.t� ;lI , . �
I Ur Mn��nCHusr;TTs
EXECUTIVE, OFFICE OIL ElNVIRONMI VT4 AIR,'i0
I)F PAl.VFM_8fq 1' OF ENVIIZONMI;NTAl, NtOl FIO /G
� ' y ONE WINTER STREET, BOSTON MA 02108 (617) 292-55 0 y�
t 'r(J�
350 MAIN STREET `9
WEST YARMOUTH, MAC 9 TRU Y COXF
508-775-2800 Secrei.Iry
ARGEO PAUL CFLLUCCI U:AVIU T3. STRUIiS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
MAP 249 PAR 035-OON
PROPERTY ADDRESS: 825 WEST MAIN STREET, HYANNIS UNIT 12 ADDRESS OF OWNER:
DATE OF INSPECTION: AUGUST 12, 1999 ROBERT YOO
NAME OF INSPECTOR : JAMES D. SEARS
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 9310 CMR 15.000)
COMPANY NAME: A&B Canco
MAILING ADDRESS: 350 Main Street,West Yarmouth,MA 02673
TELEPHONE NUMBER: (508)775-2800
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 inspection. The inspection was performed based on my training and experience in the proper
function and maintenance of on-site sewage disposal systems. The system:
X PASSES
CONDITIONALLY PASSES
NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY
FAILS p!
INSPECTORS SIGNATURE: DATE: O ��
The system Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP) within thirty(30)
days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the
system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original
should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
NOTES AND COMMENTS:
SITE OVER ALL PASSES,INSPECTION OF SYSTEM IS BASED ON CONDITION OF SYSTEM AT THE TIME
OF THE INSPECTION.THERE IS NO GUARANTEE ON THE LIFE OF THE SYSTEM.
revised 9/2/98 1
SU FACE SEWAGE DISPOSAL SYSTEM INS*ION FORM
PART A
CERTIFICATION (continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 12
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
INSPECTION SUMMARY: Check A, B, C, orD:
A] SYSTEM PASSES: YES
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR
15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B SYSTEM CONDITIONALLY PASSES: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The
System,upon completion of the replacement or repair,as approved by the Board of Health will pass.
Indicate yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not)
_ The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate
Of Compliance(attached)indicating that the tank was installed within twenty(20) years prior to the date of the
inspection;or the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank Is failure is imminent. The system will pass Inspection if the existing septic tank is replaced with a
conforming septic tank as approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s)or due to a broken,settled or uneven distribution box. The system will pa
pass inspection if(with approval of the Board of Health).
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more.than four times a year due to broken or obstructed
pipe(s). The system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
revised 9/2/98 2
SURFACE SEWAGE DISPOSAL SYSTEM INS ION FORM
PART A
CERTIFICATION(continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 12
Owner: ROBERT YOO
Date of Inspection: AUGUST 12,1999
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N/A
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect the public health,safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303
(1)(b)THT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY
AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND
SAFETY AND THE 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 soil absorption system and the SAS is within a Zone
1 of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet
of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100
feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen and is equal to or less than 5 ppm. Method
used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 3
SORFACE SEWAGE DISPOSAL SYSTEM MOTION FORM
PART A
CERTIFICATION(continued)
Property Address: 825 WEST MAIN ST, HYANNIS UNIT 12
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
D] SYSTEM FAILS: N/A
You must indicate either"Yes'or"No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR
15.303. The basis for this determination is identified below. The Board of Health should be contacted to
Determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloaded or clogged
SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an over-
loaded 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 now
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 Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy Is within 100 feet of surface water supply or tributary to a
surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach
copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate
nitrogen.
E)LARGE SYSTEM FAILS: N/A
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a
significant threat to public health and safety and the environment because one or more of the following conditions exist:
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
mapped Zone II'of a public water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local
regional office of the Department for further information.
revised 9/2/98 4
SUORFACE SEWAGE DISPOSAL SYSTEM INS&ION FORM
PART B
CHECKLIST
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 12
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None of the system components have been pumped for at least two weeks and the system
Has been receiving normal flow rates during that period. Large volumes of water have not been introduced into
the system recently or as part of this inspection.
X As built plans have been obtained and examined. Note if they are not available with NIA.
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout.
X All system components,including the Soil Absorption.System,have been located on the site.
X The septic tank manholes were uncovered,opened,and the interior of the septic tank was
inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid
depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site
Has been determined based on:
X Existing information.Ex.Plan at B.O.H.
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation
of distance is unacceptable)11 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Sub-Surface Disposal System.
revised 9/2/98 5
SORFACE SEWAGE DISPOSAL SYSTEM INSOTION FORM
PART C
SYSTEM INFORMATION
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 12
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
FLOW CONDITIONS
RESIDENTIAL: CONDOS
Design flow: 220 g.p.d./bedroom for S.A.S.
Number of bedrooms(design) 2 Number of bedrooms(actual): _2
Total DESIGN flow
Number of current residents: N/A
Garbage grinder(yes or no): N/A
Laundry(separate system) (yes or no): N/A If yes,separate inspection required
Laundry system inspected(yes or no): N/A
Seasonal use(yes or no) N/A
Water meter readings,if available(last two(2)year usage(gpd): _
Sump Pump(yes or no): N/A
Last date of occupancy: N/A
COMMERCIAL/INDUSTRIAL: N/A
Type of establishment:
Design flow: Gpd(Based on 16.203)
Basis of design flow
Grease trap present:(yes or no):
Industrial Waste Holding Tank present:(yes or no)
Non-sanitary waste discharged to the Title 5 system:(yes or no)
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: YEARLY PUMPING
System pumped as part of inspection:(yes or no) NO
If yes,volume pumped: gallons
Reason for pumping
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract.
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information:
UNKNOWN
Sewage odors detected when arriving at the site:(yes or no) NO
revised 9/2/98 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 12
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
BUILDING SEWER: N/A
(Locate on site plan)
Depth below grade:
Material of construction _ cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line
Diameter
Comments:(condition of joints,venting,evidence of leakage,etc.)
SEPTIC TANK: YES
(Locate on site plan)
Depth below grade: 2'
Material of construction X concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
If tank is metal,list age Is age confirmed by Certificate of Compliance (Yes/No)
Dimensions:
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 45"
Scum thickness: 2"
Distance from top of scum to top of outlet tee or baffle: _ 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 24"
How dimensions were determined TAPE&PLAN
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc.)
TANK AT WORKING LEVEL,INLET NO TEE,OUTLET TEE
COVERS AT GRADE,BOTH COVERS 18'STEEL
GREASE TRAP:
(locate on site plan)
Depth below grade:
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:
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural
integrity,evidence of leakage,etc:)
revised 9/2/98 7
S1*RFACE SEWAGE bISPOSAL SYSTEM IN TION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 12
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
TIGHT OR HOLDING TANK:N/A (Tank must be pumped prior to,or at time,of inspection)
(Locate on site plan)
Depth below grade:
Material of construction _ concrete _ metal _ Fiberglass _ Polyethylene _ other(explain)
Dimensions:
Capacity: Gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order Yes; No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: YES
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc,)
D BOX IS 2'X 28"
ONE LINE IN
SIX LINES OUT
PUMP CHAMBER: N/A
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,condition of pumps and appurtenances,etc.)
revised 9/2/98 8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 12
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
SOIL ABSORPTION SYSTEM (SAS): YES
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not located, explain:
Type:
Leaching pits,number: 6
Leaching chambers,number:
Leaching galleries,number:
Leaching trenches,number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number,
Alternative system:
Name of Technology:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
SIX 1,000-GALLON PRE CAST PITS.ALL PITS HAVE 2'STEEL COVERS AT GRADE.LEACHING IS WORKING
THREE PITS HAVE WATER,THREE PITS DRY
DRY PITS ARE OVER FLOWS FROM OTHER PITS
CESSPOOLS: N/A
(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(cesspool must be pumped as part of inspection)
Comments::
(note condition of soil,signs of hydraulic failure,,level of ponding,condition of vegetation,etc.)
PRIVY: N/A
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
revised 9/2/98 9
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
i
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 12
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include lies to at least two permanent references landmarks or benchmarks
locate all wells within 100'(locale where public water supply comes into house)
l �
—J�
fA;T re
0
c�
0 0 0
0 0
0
revised 9/2/98 10
SURFACE SEWAGE DISPOSAL SYSTEM IN&TION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 825 WEST MAIN STREET, HYANNIS UNIT 12
Owner: ROBERT YOO
Date of Inspection: AUGUST 12, 1999
NRCS Report name
Soil Type —
Typical depth to groundwater — —"
USGS Date website visited
Observation Wells checked
Ground water depth: Shallow Moderate _ Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to groundwater 18 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
X Obtained from Design Plans on record
Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
X Check with local Board of health
Check FEMA Maps
Check pumping records
Check local excavators,installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(Must be completed)
GROUND WATER DEPTH TAKEN OFF INSPECTION REPORT ON FILE AT HEALTH DEPT.
revised 9/2/98 q
ftfula
DEC 2 4 1996 ..
BORTOLOTTI CONSTRUCTION,INC. 10t;1pr
765 WAKEBY ROAD,MARSTONS MILLS,MA 02648 �a �AliHf °mat
508-771-9399 508-428-8926 FAX: 508-428-9399 •� "
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:
Date of Inspection:�� -/� C� 9K, Inspector's Name: t
Owne 's Name and Address: .
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper function and maintenance of on-site sewage
disposal 79tems. The System:
Passes
Conditionally Passes
Needs Further E uation By th Local Aproving Authority
Fails
Inspector's Signature: Date:
The System Inspector shall submi a copy of this inspection report to the Approving authority within thir-
ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional
office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer,if applicable and the approving authority.
INSPECTION S 1MMARY•
A)SYSJRM PASSES:
V I have not found any information which indicates that the system violates any of the failure
criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated
below.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair,passes inspection.
Indicate yes,nor,or not determined(Y,N,OR ND).Describe basis of determination in all instances. If
not determined",explain why not.
The septic tank is metal,cracked, structurally unsound,shows substantial infiltration or
exfrltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup or breakout or high static water level observed in the distribution box is due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. The
system will pass inspection if(with approval of The Board of Health):
-1 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
y: PART A
CERTIFICATION(continued)
Broken pipe(s)replaced
Obstruction is removed
Distribution Box is levelled or replaced
The System required pumping more than four times a year due to broken or obstructed pipe(s).
The system will pass inspection if(with approval of The Board of Health):
Broken pipe(s)are replaced
Obstruction is removed
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by The Board of Health in order to determine if
the system is failing to protect the public health,safety and the environment.
1)SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE
SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE
PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 Feet of a surface water
Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh.
2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 Feet to a surface
water supply or tributary to a surface water supply.
The system has a septic tank and soil absorption system and is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and is less than 100 Feet but 50
Feet or more from a private water supply well,unless a well water analysis for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool
Discharge or ponding of efluent to the surface of the ground or surface waters due to an
_. overloaded or clogged SAS or cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2
day flow.
Required pumping more than.4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped
-2-
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
F QW CONDITIONS
Design Flow: gallons Number of Bedrooms: Number of Current Residents:
Garbage Grinder: Laundry Connected To System: Seasonal Use:
Water Meter Readings,if available:
Last Date of Occupancy:
CO M .R ATAND UST IAi_ / )
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System Pumped as part of inspection:All) If yes,volume pumped: gallons
Reason for pumping:
TYPE,OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(if yes,attach previous inspection records,if any)
Other(explain):.( g�C,i i 7 K 0 S Ar,-)c Y-(pn Qu;c `i�3.
APPROXIMATE AGE of all components,date installed(if known)and source of information:
Sewage odors detected when arriving at the site: t )
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater
elevation.
Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to
a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 Feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 Feet but greater than 50 Feet from a private
water supply well with no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
'The design flow of a system is 10,000 gpd or greater(Large System)and the system is a significant
threat to public health and safety and the environment because one or more of the following
conditions exist:
The system is within 400 Feet of a surface drinking water supply
The system is 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.
The owner or operator of any such system shall bring the system and facility into full compliance with the
groundwater treatment program requirements of 314 CUR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Check if the following have been done:
✓Pumping information was requested of the owner,occupant,and Board of Health.
__L�Lqone of the system components have been pumped for atleast two weeks and the system has
been receiving normal flow rates during that period. Large volumes of water have not been
introduced into the system recently or as part of this inspection.
As-built plans have been obtained and examined. Note if they are not available with N/A.
The facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow.
'✓The site was inspected for signs of breakout.
✓All system components,excluding the Soil Absorption System, have been located on site.
,::: The septic tank manholes were uncovered,opened,and the interior of the septic tank was in-
spected for condition of baffles or tees,material of construction,dimensions,depth of liquid,
epth of sludge,depth of scum.
z/ The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM
PART C
GENERAL INFORMATION (continued)
s�
SEPTIC TANK:
Depth below grade: Material of Construction: c ncrete metal FRP_Other
(explain)
Dimisions: Sludge Depth: Scum Thickness:
Distance from top of sludge to bottom of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
1 el in lation to outlet invert,structural integrity,eviden a of leakage,etc.)T11.S ct, t'-).SCY7
OLi, z�
GREASE TRAP: 1 )
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain) — — — —
Dimensions: Scum Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments:(recommendation for pumping,condition.of inlet and outlet tees or baffles,depth of liquid
level in relation
to outlet invert,structural integrity,evidence of leakage,etc.)
TIGHT OR HOLDING TANK:
Depth Below Grade: Material of Construction:—concrete metal—FRP—Other(explain)
Dimensions: Capacity: gallons Design Flow: gallons/day
Alarm Leyel:
Comments: (condition of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:&?0(4-1))d Irc>E/
Comments: (note revel and distribution is equal,evidence of solids carryover,evidence of leakage into
or out of box,etc. i s inn-bir 2 z (,ac r al- )01- ;2z Ir gel ay V/;,V" 0
ih ono nitr/n PL)i-Lb O,? (Ve C-1-6,-)
PUMP COAMBER: /VU
Pump is in working order:
Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.)
-5-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SOIL ABSORPTION SYSTEM(SAS): ✓
(Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive
methods) If not determined to be present,explain:
Type:
Leaching pits,number:Leaching chambers, number: Leaching galleries,number:
Leaching trenches, number,length:
Leaching fields,number,dimensions:
Overflow cesspool,number:
Comments: (note condition of soil,signs of hydraulic failure level of ponding,condition of ve etation,
CESSPOOLS: U
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(cesspool must be pumped as part of inspection) h
Comments: (note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY: 0
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
-6-
Czeee'rl X(I 43.1 Kc x
'War, 622c�
lee-
X
-TAW 01/L AIV
O SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ...........
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
O
9161,
26
L)
DEPTH TO GROUNDWATER:
Depth to groundwater:_ Feet
Method of Determination or Approximation:
-7-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPEC'('ION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references, Landmarks or benchmarks.
Locate all wells within 100 Feet.
We
1 `
Cc(iifc,s q 40 )1YcG)(f, Cc1id11 no dee. Ccd idled
enJ c., os,`c c����e� 46C C����f, i:)" `-'Cct(r. ► m
� �
,Spe�.`�i'on - �Ccx�l6 4Se V��ni��1�1?(An( c
GP 7,.
Wc,rrL'os IeL)e ,
jq
nl( (oM—) O(,U�fzs 4,D g,:;cle-
ad- J-f lre o!f� 1"n_.s p ec d j
DEPTH TO GROUNDWATER: /
Depth to groundwater: l F Feet /
WOW of Determination or Agproxima ''pn:
-7 -
I
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM:
Include ties to atleast two permanent references andnarks or benchmarks.
}. Locate all wells within 100 Feet.
„6
LAC, CIO
A
Ll
a�
DEPTH TO GROUNDWATER: �1
Depth to groundwater: `7/ Feet
Method of Determination or Approximation:
-7-
._. . .BORTOLOTTI CONSTRUCTION, INC.
y a��
SUBSURFACE "SEWAGE DISPOSAL SYSTEM INSPDCTICIN FORM
Address Of.;:Property
Owner.'s Name•
Date Of Inspection / ��- �. �"`TLh):� /1,1 J C!L�3 ✓lam`(-
- --
PART.A
CflIDC KLIST
Check if the following have been,done:
Pumping information:was requested of the owner, occupant, and Board of Heal.-th.
None. of. the system coatponents have been pumped for at least two weeks and the
system has:been receiving normal flow rates :during that period. Large columes
of water:`have::not been introduced into .the system recently or as part of ti,is
inspection.
As•-Built_;plans. have. been obtained and examined. Note if they are not avail-
able with' N/A.
The facility, or dwelling was.inspected for .signs of sewage back-up.
The site.was inspected for signs of breakout..
_j,,," Al1,systecn components, excluding the SAS, have been located on the site.
_ The septic tank manholes were. uncovered, opened, and the interior of the septic
tank Iwas :inspected ;for condition of. baffles or tees, material of construction,
dimensions., depth :of liquid, .depth of sludge, dect_h of scum.
The size ard. location of the SAS on the site has been determined based on e::ist-
ing information or approximated by non,,-intrusive methods.
The facility .owner (and occupants, if different from owner) were provided with
information on'the .proper maintenance of SSDS.
SUBSURFACE. SEWAGE DISXSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFCPMATIC1N
FLOW OONDITIONS
If residential
number of bedrooms
number of current residents
garbage grinder, yes or no
laundry connected to system, yes or no
aa-scn_aj.. .use, ves or no
If nonresidential, calculated flow:
Water meter readings, if available:
� .y�,o Last date of occupancy} '9LD6-
(�ov GOAL INFORMATICN
pumping records and source of information:
Sy stemlimped part t of inspection, yes or no
if yes, volume".pumped
Reason for .pumping:
Type of system
Septic tank/distribution .box/soil absorptic�..ri system
Single -Cesspool
Overflow cesspool
Privy
/
�/ Shared,.system (yes or no) (if yes, attach previous inspection records,
if. any)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
Sewage odors detected. when arriving at the site, yes or no
s .,%MSURFA(M SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B.
SYSTEM IIUICPMATIC N CONTINUED
SEPTIC TANK,
(locate on :site plan)
depth below:grade:
material of.constructions __Z!6�ncrete metal FRP other(explain
dimensions•. .
sludge depth —
distance from top of sludge to bottom of. outlet tee or baffle
scum thickness
distance from top of scum to top of outlet tee or baffle
distance frur.bottom of scum to bottom of outlet tee or baffle
Comments:
.(recommendation for..pumping, condition of inlet and outlet tees or baffles,
depth .of .liquid.level in relation to outlet invert, structural integrity,
evidence-.of.,'leaa,ge, reccnmendations for.repairs, etc. )
:s "9060
DISTRIBUTION BOX:
(locate on site plan)
, lJaP. ih
vf-e �epth of liquid level above outlet invert
Comments
(note if level and distribution' is equal, evidence of solids carryover, evidence
of leakage into. or out of box, rec�ndat'on ro epairs, etc., )
/34 Y 4)�f Yl� D`�^
PUMP CHAMBER: y�
(locate on site plan)
pumps .in.working order, yes or no
Camments:
(note. condition ,of Pump, cham,e ,, -condition of pumps and appurtenances,
recommendations for maintenance or repairs, etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART. B
SYSTEM INFORMATION CONTINUED
.SOIL ABSORPTION SYSTEM (SAS) :
(locate .on.site plan, if. possible; excavation not required, but may be
approximated' by non-intrusive methods)
If not determined to be present, explain:
Type
leaching pits and, numberleaching chamberschambers and number _
leaciy yni�eries. and. number —
leachingltrenc'hes, number, length
leaching fields, number, dimensions —overflow -cesspool, -number
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of:vegetation, recommendations for maintenance or repairs, etc. )
zzry _
CESSPOOLS (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 (cesspool must be pumped as
part of 'inspection)
Ccmments: — —
(note condition.of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
PRIVY:
(locate on site plan)
materials of construction
dimensions ---
depth of..solids —
C mT)ents:
(note condition of soil, signs of hydraulic failure, level of ponding,
-- condi-tion of vegetation,: recommendations for maintenance or repairs, etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM' INFORMATION CanTINUED
SKETCH OF SEWAGE DISPOSAL SYSTEM;
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
i
p
� d
DEPTH TO GROUNDWATER
depth to groundwater
method of.determination or approximation:
r
SUBSURFACE:.SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate. yes, no, or. not determined (Y:, N, or.ND). Describe basis of
determination in all instances. If "not determined", explain why not.
/f1 Backup of sewage into facility?
Discharge .or ponding of effluent to the surface of the ground or
surface waters?
A/ Static liquid level in. the districution box above outlet invert?
Liquid depth in cesspool, 6" belo-a invert or available volume, 1/2 day
flow?
/ Required pumping 4 times or more in the last year?
number .of times pumped
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
/Is any portion of the SAS, cesspool or privy,
below. the high groundwater elevation?
'Within. 50,feet of. a surface water?
/" Within 100 feet of a surface water supply or tributary to a surface
water supply?
Within a Zone I. of a public well?
w Within, 50 'feet of a private water supply well?
Within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, net the SAS)?
/ Less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis' If the well
has' been analyzed .to be acceptable, attach copy of well water analysis
for coliform. bacteria, volatile organic compounds, amonia nitrogen
and nitrate nitrogen.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector: 0 6e4 J � --
. Company Name. (-`TU��M t (J!' �� �1 C • __
Company Address � 5 Zt
��` dl
Certification Statement
I.certify, that I have personally inspected the sewage disposal system at
this.address and that the information reported is true, accurate and
canplete-as:of the time .of inspection. The inspect�:on was perfoniTed and
any recom*--ndations regarding upgrade, maintenance and repair are
consistent.with my`training and experience in the proper function and
maintenance of on-site sewage disposal systems.
(deck e
I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
3,10 CMR 15.303. Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
.. I have determined that the system fails to protect public health and
the: environment as defined in 310 CMR 15.303. The basis for this
determinimation is provided in the FAIUJRE CRITERIA section of this
form.
Inspector's:Signature -
Date
Original to System Owner
Copies to:
,Buyer (If applicable)
Approving authority
Date:17// 12,'i
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF tY \BUSINESS: 1� 0V f; �— . C I � �lA � 0,/q y) yM-S rA p
BUSINESS LOCATION: S `.� I r'1 n-t I INVENTORY
MAILING ADDRESS: e r Iz TOTAL AMOUNT:
TELEPHONE NUMBER: as
CONTACT PERSON:
EMERGENCY CONTACT TELEPHONE NUMBER: C�`� �0 S4 C1 MSDS ON SITE?
TYPE OF BUSINESS: C. ( caCA YN
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED -
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt&roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform,formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach)
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar,removers
Windshield wash '
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS -'Applicant's Sig re Staff's Initials
I
{�� <.-" are' � _. .�....v. �. _X �.r-«. � � ��. s� �'
'�
�- �'
.� �, �� �
�/' I
�-" I
.\
_ ___
. - -• / R
•MPLE' TtTHIS�,�SECTION: COMPLETE THIS SECTIONON DELIVERY
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. X Agent
■ Print your name and address on the reverse Addressee
so that we can return the card to you. B. Received by(Printed Name) C. of De' ery
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
D. is delivery address different from item 1? ❑Ye
1. Article Addressed to: If YES,enter delivery address below: ❑No
1
I
3. Service Type
C a c1�C t v 1 t (`(�R O ZJ4 3'Z OLCertified Mail ❑Express Mail
❑Registered 5L Return Receipt for Merchandise
❑Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number r s}l
(rmnsfer from service label) 7006 0 810 0 0 0 0 .3 5 2 4 8 6 0 8 &4
PS Form 3811,February 2004 Domestic Return Receipt 102595-02-M-1540
UNITED $TAT s'PdW .:...- ,....,.. �; ,�„a•gp�'=� •.. ��
,'- alas
•
a '.n n
• Sender: Please print your name, address, and ZIP+4 in this box'
ETown of Barnstable
alth Division
0 Main Streetannis,MA 02601
I
a
Certified Mail#7006 0810 0000 35 4 8608 _
0k'TKV ~s Town of Barnstable S 7
Regulatory Services
BARWrABLE, • l
9 MASS. Thomas F. Geiler,Director
�pA 1.639 ♦0
'f¢""A�A' Public Health Division �-
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
February 26, 2007
Thomas & Cecilia Lee
13 Harbor Hills Road
Centerville, MA 02632
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000, STATE SANITARY
CODE II— MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property owned by you located at 825 West Main Street Unit 12, Hyannis was
inspected on February 26, 2007 by Timothy O'Connell, Health Inspector for the Town of
-Barnstable. This inspection was conducted on the basis of the rental registration in
accordance with Chapter 170 of the Town of Barnstable Code.
The following violations of the State Sanitary Code were observed:
105 CMR 410.500—Owner's Responsibility to Maintain Structural Elements.
Cracked wall surrounding fireplace.
You are directed to correct the violations listed above within thirty (30) days
of your receipt of this notice by repairing cracks in walls surrounding fireplace.
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.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
QAOrder letters\Housing violations\Rental ordinance\825 West Main Street Unit 12.doc
i
PER ORDER OF THE BqARD OF HEALTH
T oma�sM Kean, R.S., C -
Director of Public Health
Town of Barnstable
Cc: Susan Tirante, Tenant
Cc: Timothy O'Connell, Health Inspector
QAOrder letters\Housing violations\Rental ordinance\825 West Main Street Unit 12.doc
r
Certified Mail#0000 0000 0000 o000 0000
t t Town of Barnstable
Regulatory Services
Thomas F. Geiler, Director
Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
r�aS.L_�T...L�•��IA �..S�L date
ead .
ery 1!110 PA oa,Co3.2
city,state,zip
NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000 STATE SANITARY
CODE II — MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION
AND THE TOWN OF BARNSTABLE CODE CHAPTER 170.
The property,owned by you located at AQ 6 W95� MC1iAU 5 was inspected
03=2 ^0-2-WM4b (Address)
(date) (Inspector's name)y � , Health Inspector for the Town
(d
of Barnstable,
(Reason for inspection)
The following violation(s) of the State Sanitary Code were observed:
(State code violation number-violation description)
105 CMR 410 SHOO _ r
CYOt.0�C,e ;
105 CMR 410.
105 CMR 410.
105 CMR 410. -
Q:\Order letters\Housing violations\Rental ordinance\template.doc
105 CMR 410.
The following violation(s) of the Town of Barnstable Code were observed:
(Town code violation number-violation description),
§170-_ -
§170-_-
You are directed to correct the violations listed above withi � (�. ) days.
(writt W
of your receipt of this notice by �ern,,r t U y c It1,9 1 Q Q,QS
Y "
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.
Non-compliance will result in a fine of $100.00 per violation. Each day's failure to
comply with an order shall constitute a separate violation.
Should you have any questions regarding the above violations, please contact the Town
Health Division and ask to speak with the inspector who performed the inspection.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean,R.S., CHO
Director of Public Health
Town of Barnstable
Cc: lZSGt i YQl1�+"�
(Name,tenant,owner,Fire Dept.,Building Dept....)
Cc:M
(Health inspector's name)
(Generic codes located at QAOrder letters\Housing violations\Rental Ordinance\GENERIC CODES.DOC)
QAOrder letters\I-ousing violations\Rental ordinance\template.doc
1n brxLa
-
r
Parcel Detail Page 1 of 3
UN A111
x pijyyf
Logged In As: Parcel ®Qta I _ Monday, Februa
Parcel Lookup
.•
Parcel Info
Parcel ID 249-035-OOL Condo Unit UNIT 12
Condo
Complex ISEA CAPTAINS Building jCAPT BREWSTER �-
Location;825 WEST MAIN STREET ______' l Pri Frontage
Sec Road L---- - -------- 1 Sec I-- -- - ----- —
1 Frontage J
Village IHYANNIS Fire District fHYANNIS
Sewer Acct I Road Index'1813
Interactive -
Map
Owner Info
Owner LEE, THOMAS SR TR I Co-owner FLEE REALTY TRUST OF 2002
Streets 13 HARBOR HILLS RD Street2
city CENTERVILLE State MA zip j02632 country i
Land Info
Acres 10__ _ use`Condominiu MDL-05 zoning B Nghbd 0001
-_ _ .......... --- - -- -
Topography( Road
Utilities Location I
Construction Info
Building 1 of 1
Year 1974 Roof Gable/Hip ExtiBrick/Masonry
Built I Struct Wall
Effect 1840 Roof Asph/F GIs/Cmp AC'None
Area Cover Typef
Style sCondominium ] Int Drywall Bed �2 Bedrooms
Wall Rooms'
ooms
Model Res Condo Bath!Int
Floor Rooms
http://issgl/Intranet/propdata/ParcelDetail.aspx?ID=17952 2/26/2007
Parcel Detail Page 2 of 3
Grade Avera e Heat T ical Totai 4 Rooms
g Type yp Rooms
SMT[d22]
Fuel ( a
Stories 1 Story Heat _ ___.__ ._ Found-
tion _ ^�
Permit History
Issue Date Purpose Permit# Amount Insp Date Comments
Visit History
Date Who Purpose
- -- —_ -------------
Sales History
Line Sale Date Owner Book/Page Sale P
1 7/25/2002 LEE, THOMAS SR TR 15402/134
2 9/29/1980 LEE,THOMAS F&CECILIA H 3162/288
Assessment History
Save# Year Building Value XF Value OB Value Land Value Total Parcc
1 2007 $191,800 $2,600 $0 $0
2 2006 $172,800 $2,600 $0 $0
3 2005 $154,300 $2,600 $0 $0 ;
4 2004 $135,400 $2,600 $0 $0
5 2003 $62,900 $2,600 $0 $0
6 2002 $62,900 $2,600 $0 $0
7 2001 $62,900 $2,600 $0 $0
8 2000 $45,500 $2,300 $0 $0
9 1999 $45,500 $2,300 $0 $0
10 1998 $45,500 $2,300 $0 $0
11 1997 $54,000 $0 $0 $0
12 1996 $54,000 $0 $0 $0
13 1995 $54,000 $0 $0 $0
14 1994 $49,500 $0 $0 $0
15 1993 $49,500 $0 $0 $0
16 1992 $56,400 $0 $0 $0
17 1991 $85,900 $0 $0 $0
18 1990 $85,900 $0 $0 $0
http:His.sgl/Intranet/propdata/ParcelDetail.aspx?ID=17952 2/26/2007
IParcelDetail Page 3 of 3
• 19 1989 $99,600 $0 $0 $0
20 1988 $63,800 $0 $0 $0
21 1987 $63,800 $0 $0 $0
22 1986 $63,800 $0 $0 $0
Photos
http://issgl/Intranet/propdata/ParcelDetail.aspx?ID=17952 2/26/2007
` r
r
FoVM30 �� Hoessa WARREN'" THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF H LTH
CIT /TOW
W
DEPART T 0,2-6d
ADDRESS
Ar SV6 a
TELEPHONE
c
Address IW'-v � Occupantt"'
Floor Apartment No. No. of Occupants
No. of Habitable Rooms � No.Sleeping Rooms—
No.dwelling or rooming units 0—A No.Stori
Name and address of own r
-- - — - - — F4'Remarks Reg. Vio.
YARD Out Bld s.: Fences: p ,L
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE EXT. Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows.-
Roof
Gutters, Drains:
Walls:
Foundation:
Chimney:
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Lighting:
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceilin : Ll to ., 5 ov
Hall Lighting:
Hall Windows:
HEATING Chimneys:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents:
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.:
❑ 110 ❑ 220 Fusing,Grnd.:
AMP: Gen.Cond. Distrib. Box:
Gen. Basement Wiring:
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Living Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas, Oil, Elect.:
SAGk�, Flues,Vent , feties:
Kitchen Facilities tirikj
ove
Bathing,Toilet Facil. Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation .Rats,•-Mice,Roaches or Other:
Egress Dual and Obst'n:
General Building Posted
f Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR. (See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJ�jURY."
�4
INSPECTOR TITLE I 4�
C —
DATE D_ TIME �( ✓
A.M.
THE NEXT SCHEDULED REINSPECTION P.M.
„ ,.. r,r y..,'f. ,s':ir!' '� 1' w f•roi'ry..zt •. SA:r� .-g;X,+iY ,. .r ...,+� n:�.r,�.
M"
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in.residential premises, shall be deemed conditions which may endanger or
impair the health, or safety and well-being of a person or persons occupying the premises. This listing is composed of those
items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the
occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for
human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so
in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that
other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local
health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to
include affect the legal obligation of the person to whom the order is issued to comply with such order.
(A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary
needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer.
(B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as
prohibited by 105 CMR 410.200(B) and 410.202.
(C) Shutoff and/or failure to restore electricity or gas.
(D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com-
mon area required by 105 CMR 410.254.
(E) Failure to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR
410.150(A)(1)and 410.300.
(G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object,
including garbage or trash, which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452.
(H) Failure to comply with the security requirements of 105 CMR 410.480(D).
(1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar-
bage, rubbish, filth or other causes of sickness which may provide a good source or harborage for rodents, insects or other pests
or otherwise contribute to accidents or to the creation or spread of disease.
(J) The presence of Ieadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public
I Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.)
(K) Roof, foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or
other dangers or impairment to health or safety.
(L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating,
gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352,
so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety.
(M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release
of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105
CMR 410.353.
(N) . Failure to provide a smoke detector required by 105 CMR 410.482.
(0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or
knowledge of the owner of said condition or conditions:
(1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven
or any defect that renders either inoperable.
(2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any
defect which renders them inoperable.
(3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of
generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard.
(4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as
required by 105 CMR 410.503(A)and 410.503(B).
(5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550.
(P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con-
dition which may endanger or materially impair the health.or safety and well-being of an occupant upon the failure of the owner.
to remedy said condition within the time so ordered by the Board of Health.
I
L
1
, .THE Town of Barnstabo
s F Tp�
Regulatory Services
• Thomas F. Geiler,Director
9q,A ,' : ��� Public Health Division
TED N10�s Thomas McKean,Director
200 Main Street, Hyannis,MA 02601
Office: 508-862-4644
Fax: 508-790-6304
August 18, 2003
Maxine C. Harding
825 West Main Street
Unit#1
Hyannis, MA 02601
NOTICE OF VIOLATIONS OF 310 CMR: 15.00 THE STATE
ENVIRONMENTAL CODE TITLE V: MINIMUM REQUIREMENTS FOR THE
SUBSURFACE DISPOSAL OF SANITARY SEWAGE
According to Water Pollution Control records, the septic system on the property owned
by you located at 825 West Main Street, Unit #1, Hyannis, has been pumped seven (7)
times in the last three months. The following violation of 310 CMR 15.00, the State
Environmental Code, Minimum Requirements for the Subsurface Disposal of
Sanitary Sewage and 105 CMR 410.00 State Sanitary Code II - Minimum Standards
of Fitness for Human Habitation:
105 CMR 410.303:
Septic system is in hydraulic failure. Septic system has been pumped a total of seven (7)
times in the past three months. As outlined in 310 CMR 15.000, Department of
Environmental Protection's Title V, a septic tank or cesspool that is pumped more than
four (4) times in one year is said to be in failure.
1) You are directed to keep the on-site sewage disposal system pumped as many times as
necessary (daily if need be) to keep it from overflowing onto the ground.
2) You are further directed to contact and hire a professional engineer to design an
Innovative/Alternative (IA) septic system which meets local and state regulation
requirements within fourteen (14) days of receipt of this letter in order to repair this
system or connect to town sewer. The reasoning for requirement for an lA system is
under Town of Barnstable Board of Health Regulations Part VIII, Section 15.00. The
regulation states: "Any residential condominium development with a failing septic system
and with a total wastewater design flow of 1,650 gallons per day or more" must install an
1A septic system. There are twenty-four (24) units in Sea Captain Village, and at an
absolute minimum of 110 gallons per day (1 bedroom units), there is a minimum daily
flow of 2,640 gallons per day, well over the 1,650 maximum.
3) The-new-ly iristalled_septic system shall be completed on or before October 20, 2003.
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.
Non-compliance could result in a fine of up to $500.00. Each day's failure to comply
with an order shall constitute a separate violation.
PER ORDER OF BOARD OF HEALTH
Thomas A. McKean
Director of Public Health
l U2 �� I
5 C CL vvs
�i
- (� asp W A ,
k+p
/r_3\
U
40
c��►c r ..i y O•T 3 � //�y�/p
QEc•o�T 0
0
r
i
i
b
` N
U
I � _
'o i 3 11 a,C6•L'a T ��
O
000,
e_ e-0
0 .
/o
,� , RESPONSIBLE
vo. 3 ,o} I ' ACTOR IS
THE CONTRA
FOR NOTIFYI CG�!LAt I ILLE gOS—
+'S) AEALTH OF' 9��'7-106t), FOR
pITAL, TL RIQU
$ f� INSPECTIOI S AS DATEIAPPROVING
fi �J w o 1 FETTER OF SAME
' ^ ✓� �' THESE PLANS..
6�Nc�J I r.v t'� - �. *?PROVED
ii •, c
J ,
Mass. Department of Public Health
Divis' of Enuironmenta, Health
Date_0 3
f .TvBSo,
I
,� Fig c�c�Ti E S � •!.o .P:� :c yc � wi T�
i
GG�iq�J Sf! V O. N,•.. I G„!/f 5r .� _.� J 3 •'9
,z i"J�-C_ L Gamic tfi nJs- fN c i c. T,-�S �- i.l S 1 �,'�'t, I •y,L c t - . -��.*03 .e v _ •-r �i,.J ;-' t/ .. �. /ii/. _> i /
,���v ��97_h/ T.�C .Ci9./��t/�nJ T �Nvs-T { �y+i? r '7 /J C` J� `?✓ � � -
ZO ..O/90'Nc7 i
- I ' � _ .. I ! 1� y'•��'.: ."'�'-G., n L G G<J EST /Y>f� "\/ �.
PPP -a ✓� .���/� � /LJ H S J ,
. . � ` )'i � �i �n Ems•' J ��S i/ti1�•JTS O.t G'��E C� J � ,-✓C'
1 I j
�3
.S 115, TS
l r _
FLOOR BOX FRAME AND LID N ��
6'I R-35 40 PVC OR NEENAH R-7506 OR EQUAL 1v, STATE H&WAY RJIM Z$DESIGN DATA RISER PVC PIPE W/S.S.CAP SCREW LID J
RISER 24"SQUARE (� N
r--- - CLOSURE Lu
f�AV+=MENT (�
DAILY FLOW: (ZD) BEDROOMS x 110 GPD =�?�� GPGI cLAss"c"coNCRETE lo" _ =gN
_.- Z J - ' w 95%COMPACTED FILL F
PIPE TO BE LAID LEVEL FOR �. � SEPTIC TANK:ZZoo P w
-, GPD x 200% _ �7/�o G. D o
2' OUT OF DISTRIBUTION BOXL -2� ' > USE: (� GALLON PRECAST SEPTIC TANK ( '' / : __ _.
/ ,�n/C 7.�J ✓ \ w g m 4
DISTRIBUTION BOX: o z I) 1 ! IN
g
4' SCH 40 PVC PIPE 3/4" - I I/2" DL iJBLE WASHED STONE USE: DB-// �,�-Zo) c)¢Lu lu 1 7 7'ia/L m
w �- - � I - ` a IL
O.F. _ _ SOIL AB3PTION�YSTE = i - -„J ° < g her
@
—__ OP L EL 7/ L la/�! USE /�. .�:��/ :� z -
1
_. ..J.p �..i,.rr.J �C' ` Of
VG -l'` w 1 _ ,-j ' r. -i:` 1 a^r'_.•_.._.. -. -= vp
23" GGJ�T�G s:r7.�T/G=1.:.T�/� /00 s _ , .� _ �` _ 1 .i ..1� Ifs - _ i'1.�_ 7 , +� i..- 1=d r: \j
- / , sl.�%� �- 1 I' `` { _ � r '.I . } r
0.3 �. BOTTOM @ EL y_ I, I y F
I :j
N`TALL CA`i[iAl 1 LL ^ I J`
1 Cps(/�T 1 N OUTLET TEE J >✓^ c'� E'G `!/�'; J C �Tr�-a-I �.-- CAPACITY: 1 2 IN.DIA.WASHED, (n
/ ✓ �I
SIDEWALL AREA: / CRUSHED STONE ., �. +t, �- - I I - I , �
E .G0 yr 7�.. C. �OlL JTa,✓� / �. -� —, SURROUNDING CHAMBER I a I J i (n
BOTTOM AREA: .3� �C 5 r>J. 7fl Z � .5.: _ /�',� L Il I �GUS
/ ..., i,� r r u-, 1 �- _r r -I.-I .i r .:i� i -r:;r .r -x r u-r-r._LL�ol ��
AND INSPECTION PORT 1 d< - _ s
ASSEMBLY FROM Q
BOTTOM TO FINAL ELEVATION TYPICAL CULTEC CHAMBER 1 4 OZ.NON-WOVEN FILTER FABRIC !
�'@ EL. � _,� I 6"INTERNAL COUPLING
BOTTOM TM N THIS CHAMBER ONLY) v
INSPECTION PORT --' AROUND STONE
SEPTIC SYSTEM PROFILE
E
Typical Inspection Port Detail for Traffic Appli;;�tior•.s DEEP OBSERVATION HOLE LOGS
PAVEMENT
1-2 INCH WASHED
CULTE( CRUSHED STONE 95% COMPACTED FILL DATE: Sc ,
- w HEAVY DUTY r'F - '
C�JLTEC No. 410 FILTER FABRIC
0 NIW S!D OF ST(INE _ Y.
VAS I N1=:5.
� TOE 'u ES E
L `
\ DEF�TH PER PERC RATE: C Mom,✓,�i.,/��r I
DESIGN 14rr S" 111N.
14'MAX. c: ,�
MIN.' ,
I DEEP'�BS RVATION HOLE #I EL
1 s _1 _- Err MIN. Df'PTH ,
-+ SOIL SOIL SOIL COLOR SOIL
fKOrvi OTHER -
HEIGHT
TEXTURE MUNSELL) MOTTLING
l I / �--_ _ � r✓ � - �" w CHAMBER 51JK-AC,'--
HORIZON_
HEIGHT
a - IN -,;_;,
6 MIN.
7 '/~ C% ,t�Y ��.vr> z,sy GAS/
+
Ls
12" - CHAMBER WIDTH-� 6"TYP. /Vo GvAT�f' c.,/Gou.v TC-,�Ep
TYP.
!' \ DEEP ODE KVATION HOLE #2 EL.
o'PTr! '
I'
1� ` F .OM SOIL SOIL
SOIL COLOR SOIL
Paved Traffic Septic Detail HORIZON TEXTURE OTHER
M SUf-AC P (MUNSELL) MOTTLING
V 1 ._�� �. � �;:.. ,, 3` �=%caJ L C�s�.�•. y .�•a ry v /u y.t r:>%
'7 7; � ,''�'o" C2 COf�.�'✓.c—�rJ, .,..:v�+.v.!/ z,Sy
I
�\ \ \ DEEP 0D.'';ERVATION HOLE #3 EL.
`� ` ` �Pl H
O O ` '^` SOIL SOIL
SOIL COLOR SOIL OTHER I
e y) (MUNSELL) MOTTLING
�j✓ r�/p "� "' I HORIZON TEXTURE
- _ I
DES' OB:=5ERVATION HOLE #4 EL.
CI=PTt1 SOIL SOIL SOIL COLOR SOIL
HORIZON TEXTURE OTHER
SI \FAGS (MUNSELL) MOTTLING
�r ��� J i / .S/Zz7 To/�-/9 ( ✓ /l V I 4
if
I:
a � �f ; OENEP�AL NOTE _
s
T,8X—' CC , r �"S/�v —CT Zoo, �,t,•� �`�� � ' ,
r
I CONTRACTOR TO�E RESPONSI f5LE FOR THE LOCATION OF ALL UTILITIES,
ABOVE AND UI�DERC�ROUND,PRIOR TO ANY EXCAVATION OR CGIVSTRUGTION.
f- end ,�Cep I
2. SEPTIC SYSTEM TO f5E I NSTALLED I N COMPL I ANC1=WITH 310 GMR 15DO:T,1;L!_
ter= ��.-�s�=w . .r-�,�-✓: � '�/� - � /
f 3. THIS PLAN I S NOT TO E USED FOR PROPERTY L! TE I ,13 R Y NE PE TERMINATION
y
ALL D I S I V Pvc=D AR.FAS TO 15E LOAMED AND SEEDED �
�.� A41-1 ,
� � S ATE --- � Env AG E �"LAB
,/ `� /
,� / 5. CONTRACTOR TO PROVIDE�&HOUR T � I�; ., UR NO ICE FOR ANY rNSPEGTION •
G. EX�T I NE5 SEPT G SYTEMS TO f5E PUMPED DRY AND FILLED WITH SAND. fop,
/ 7. SEPTIC SYSTEM IS NOT DESIGNED FOR&ARf5A0E DISPOSAL. 8 �S ��� �T" �i�/,`/ —.57'
PREPARED FOR I
ICI
'j � SCALE: �s DATE: DRAWN BY: r
JOB NUMBS REVISION: SHEET NUUM13ER:,/ s
4 r
f ? i
. '�4 t�` /' '�'"►° WELLER � ASSOCIATES
1 645 FALMOUTI-1 RD., SUITE 4C -�- P.O. BOX 4 1 7 CENTERVILLE, MA 02632
. "- ..., '�'��"�u>r'r+� 'r' _ Yam, . ., Y,• I
2 WINDY WAY, #232 NANTUCKET, MA 02554
TEL.: (508) 775-0735 -�- FAX: (508) 775-0754
1 - EMAIL: tri5weller@COmca5t.net
I PROFESSIONAL ENGINEERS LAND 5URVEYOR5
f N R 5 LA,n°12� s V
1 i V ACT-12
K ,
/3 o �
In,
C
S iPpo�714 I �.
CF-
-o I
C _ _ 7-o
Mil s 7-` 8 ^' 3 6
a I
I•
8` F
• ,�C/t-i o✓F �o.�! C o roc i1S' /� G i9 i�J � !�/ G
a� /S T•e'18 iJ T / O 1J .B O � � �• `- � T E r ]�r" y� C•/ �E
�f -9 e E— � '_ / ' WSJ �-- l
3'a+,n�. �' y - ,PE/•-�fp�l E
--�—
i /s
�lt�'. t t ✓ � Pam_.� i �7 � � � •��'�.
73
t
yEv. F2r?/. = /Oi.0ore�. C< <v 'E�jo
So ..
T ,
?.e o+ LoA•y i faSoi� _ �o/fnw IS�B.So L ?,o' s�iBseiL O y G/ U /
Z s a Lo^M ,
i
f
Bm wE Y
G.S S��✓E� B o'
N O71V-1-or at
�srq►is.��) �9 _ V
f
1� ' 1
T,odg
O
So�G TESTS - _
i 1
.� E I 'i
,8 y-- ,moo�3E,e 7-- fA S-/9 O T.si •
��ss �• �- H. �esT f� •
k 3= /0 3. So
t-
y_
�EMG�J E C o w c. �•p v�,E' S F .tE o c.s+c E
E, /✓.C. /. ,silfyNHact si CCF
7'--
c'ovE -2
O� ,8• T.- C o J
Illy
•D/1 Zy`D q,
yC./, PIPE 'C, i�E +�
2
•J` .0 �Lsyd.rr J o� Vd%s•vSu -517 Ni F,zEE F2oi•-• �•fo...
JF
�.E•E�/�S T 3E D'/G '^^J/a- %ic/(�,iE 'J. /NC/. E L E(/. rQ�1Ec �+ S ;•_
a AJ
Bo rT� • y,T`
s
. Ec_E�/ ti :. , . ' ELE[/ ,�; a >� iG
� /•J U. E LE cJ
v Y$.w /-#0? = Jr3 r rC'i3 5`3.0O
3
1 • ' Y'3 ��/t' ":a S .4 s. �{ "J..``• s 7 /• O O �" /O. 'jj•� �L.)i�.. l,t ;� r 9f/.So _-
ory . /0 0.
€ cViv TES Tf�,Bc F z ,� ,
� Pp 0 VED
4
f � ; Mass. Departme
nt of Public Health
PauDIVIS of Environmental Health
l
.Q7.
t
i Sf/C-ET Z of � STD' ETS ✓o a� 'r .2Z - a'ii