HomeMy WebLinkAbout0125 WINDSHORE DRIVE - Health 125 Windshore Drive
Hyannis
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TOWN OF BARNSTABLE V
LOCATION SEWAGE # 06
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INSTALLER'S NAME&PHONE NO. 1
SEPTIC TANK CAPACITY 5ff
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NO.OF BEDROOMS
BUILDER OR OWNER
F-ERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Uaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
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c Commonwealth of Massachusetts 07:W— 3-4-
G :. p Title ,5 Official Inspection Form
<iI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V 125 Windshore dr
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is required for every Hyannis Ma. 02601 6-30-20
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 �'/. iL4ua-i-
on the computer,
use only the tab Michael Sears
key to move your Name of Inspector
cursor-do not Robert B Our Co INC.
use the return Company Name
key.
363 Whites path
Company
� Company Address ,
South Yarmouth Ma. 02664
City/Town State Zip Code
508-477-8877 S114430
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
OF
2. ❑ Conditionally Passes
M I C H A E L
3. ❑ Needs Further Evaluation by the Local Approving Authority o SEARS
,_
* No.SI 14430 '-
co
4. ❑ Fails ;'. of to. q-
ON, f51 1111
6-30-20
Inspector' ignature 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
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
�ii Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
125 Windshore dr
V�
Property Address
James Michael Sorenson Jr& Judee Anne Korab
Owner Owner's Name
information is required for every Hyannis Ma. 02601 6-30-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System 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 Form
5 al Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
t,-
125 Windshore dr
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is required for every Hyannis Ma. 02601 6-30-20
-
page. City/Town J 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 ❑ 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:
l5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
f
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ b Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
c � 125 Windshore dr
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is required for every Hyannis Ma. 02601 6-30-20
-
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
❑ ® 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
Title 5 Official Inspection Form
�I Subsurface Sewage Disposal System Form Not for Voluntary Assessments
c / 125 Windshore dr
u
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is
required for every Hyannis Ma. 02601 6-30-20
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 'h 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.
❑ ® An portion of a cesspool or privy is less than 100 feet but greater than 50 feet
YP p p Y
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
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
f
�I; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Windshore dr
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is
required for every Hyannis Ma. 02601 6-30-20
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes"to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health:
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
1p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
>r
125 Windshore dr
u�
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is
required for every Hyannis Ma. 02601 6-30-20
page. Cityrrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Description:
Number of current residents: 2
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)):
NA
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: presentDate
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
°�, Commonwealth of Massachusetts
Title 5 Official Inspection Form
lI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
125 Windshore dr
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is
required for every Hyannis Ma. 02601 6-30-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
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:
Source of information: 11-26-18
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
r
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 18
r
Commonwealth of Massachusetts
�v Title 5 Official Inspection Form
iI Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
125 Windshore dr
V�
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is required for every Hyannis Ma. 02601 6-30-20
page. CitylTown 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:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 22"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.):
l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
tii; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Windshore dr
u—
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner. Owner's Name
information is required for every Hyannis Ma. 02601 6-30-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500 gal
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal
Sludge depth:
4"
Distance from top of sludge to bottom of outlet tee or baffle
24"
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 12
How were dimensions determined? Sludge gudge, tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
1500 gal tank woth outlet cover at 1' below grade, inlet cover under deck with both in and out tees
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Windshore dr
u
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is
required for every Hyannis Ma. 02601 6-30-20
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
125 Windshore dr
V
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is
required for every Hyannis Ma. 02601 6-30-20
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding 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):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D box is 16x16 with 2 outlet pipes, cover at 30" below grade
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
125 Windshore dr
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is required for every Hyannis Ma. 02601 6-30-20
page. Cityrrown 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:
® leaching chambers number: 5
❑ 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
cam, Commonwealth of Massachusetts
:. Title 5 Official Inspection Form
iIo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
125 Windshore dr
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is required for every Hyannis Ma. 02601 6-30-20
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.):
SAS is 5 Infiltators with no sign of 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.):
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
li; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Windshore dr
u
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is required for every Hyannis Ma. 02601 6-30-20
page. City/Town 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
c !% 125 Windshore dr
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is Hyannis Ma. 02601 6-30-20
required for every State Zip Code Date of Inspection
page. Cityrrown
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
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t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 16 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Windshore dr
V
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is
required for every Hyannis Ma. 02601 6-30-20
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water:
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting-pro perty/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers - (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 18
f
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
III; Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Windshore dr
Property Address
James Michael Sorenson Jr&Judee Anne Korab
Owner Owner's Name
information is Hyannis Ma. 02601 6-30-20
required for every State Zip Code Date of Inspection
page. City/Town
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
7ee AS
i
s
N o 6—nW W"0-r
Title 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 18 of 18
t5insp.doc-rev.7/26/2018
9
No. FEE v D
C OMM,ONWEA LTH Of MASSACHUSETTS
` Board of Health, MA.
PPOWION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repai>Xupgrade( ) Abandon( ) - b Complete System �ipdividual Components
Location S Lj i E Owner's Name C�
Map/Parcel# Address
Lot# Telephone#
Installer's Name Designer's Name
Address S e� s Address
Telephone# Telephone# _
Type of Building \ yCn, Lot Size S 4�1 sq.ft.
Dwelling-No.of Bedrooms C;x Garbage grinder (4A,
Other-Type of Building No.of persons_r�> Showers ( cafeteria (V
Other Fixtures C�• ���C � �
Design Flow (min.required) gpd Calculated design flow sign flow provided gpd
Plan: Date 1 ®11C Number of sheets ` 1'Revision Date pp�
Title C>n!sp So nk-:,,r - ^'Z—KA
Description of Soil(s)
Soil Evaluator Form No. Name of Soil Evaluator noctgn ate of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS
The unders fined agrees to install the ove described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further afire to not tDj2lace the In' peration til a Certificate of om liance 16.been issued by the Board of Health.
Sig ed Date
Inspections
I.'�. "�6+ -�� - A•'L��ty�1'N '7`'"�LJ""�Si•�"�[.J•-��+�. �f'r�TK'�'°m'n'1>s',.e"'aT � ., _ ;��„�„-.�.,r""1fZy^�"�7.' .+w.f'�y�"1✓M��#(`���1:�.,�,.r.,_`r'`��. -
ifNo: l t FEE
F MASSACHYSE 11
'Board of Health, \4—'— , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
t
Application for a Permit to Construct( ) RepaiXUpgrade( ) Abandon( ) - 0 Complete System *-dividual Components
Location I ZS Lj 1 rVnfQ C < Owner's Name ► \ CA0.-- p czc
Map/Parcel# 2 , ,'J Addresses-� ME
Lot# } j Telephone#
Installer's Name Desi ners Name
t �S '
;g 5 a �nu�co \ SJ
Address Address t S GC-A
n Ins
Telephone##, _ Telephone# 1j _ 99_A jg ; 4
Type of Building S\C\Pn�-�C.,\ Lot Size S . 4 5 s ft.
1 9•
Dwelling-No.of Bedrooms ^�C.� L oZ ) Garbage grinder
Z
_ Other-Type of Building 0,0 No.of persons_r�> Showers ( )WEafeteria
Other Fixtures oc K1�C �lhLc Lp �
2 v
Design Flow (min.required) J V gpd Calculated design flow_=222�0 sign flow provided 3 t • gpd
t rPlan: Date \ 4 Number of sheets Revision Date
E Title Uri A
p� Description ofSoil(s)r
Soil Evaluator Form No. Name of Soil Evaluator ate of Evaluation t J�a�10 4
I
DESCRIPTION OF REPAIRS OR ALTERATIONS
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the system_m, operation until a Certificate of t om fiance has been issued by the Board of Health.
Sig,ed Date (/ v
Inspections ;
4
�a ry
-
.
No. U0N- qoo FEE
COMMONWEALTH Of MASSAC14USETTS `.. .
Board of Health, 8 ". .- 17 MA.
CERTIFICATE OF COMPLIANCE
f Description of Work: �IIndividual Component(s) ❑Complete System
The undersigned hereby,certify hat the Sewage Disposal System; Constructed ( ),Repaired ( ),Upgraded Abandoned (
by: //,,�� r� r
at f /` / IU�V
has been installed in ccogan�with tl e pro�'sio s of 310 CMR 15.00 (Title 5) and the approved design plans as-built plans relating to
application No. ``�� 7 dated 0 A roved Desi-r�,Flow (gpd)
Installer /'
Designer: _ Inspector: ,_Date: ! `1
The is�suan'ce.�of this permit shall not be construed as a guarantee at the system will function as designed.
.. No. C .� /Q FEE
COMMONWEALTH OF MASSACHUSETTS
Board of Health,
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is heXe
y granted to; Construct() �'Reerp�air( I) Upgrade(� Abandon( ) an individual sewage disposal system
at [/'.) � !/! Ili�(�f T7(�� ��>S as described in the application for
• r �
Disposal System Construction Permit No. dated
Provided: Construction shall be completed within�thhr�ee years of the dat of this er t All cal conditions must be met.
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date t b/��r Board of Health
a..f
'1
TOWN OF BARNSTABLE
LOCATION � � (A.Jf1 ' - SEWAGE #
j VII,LAG ASSESSOR'S MAP & LOT
INSTALLERS NAME&PHONE NO.
• SEPTIC TANK CAPACITY �� 5
LEACHING FACILITY: (type) 1L` (size) -
I
NO.OF BEDROOMS
BUILDER OR OWNER.
PERMTTDATE: COMPLIANCE DATE:
• Separation Distance Between the:\
Maximum Adjusted Groundwater Table and.Bottom of Leaching Facility
Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)
Feet
Ede f Wetland and Leaching Facility(If any wetlands exist
g 0 Feet
leaching facility)
300 feet of 1 g
within
Furnished by
4/
j4g '
1601 ��
Town of Barnstable
°ptNE t°'r Regulatory Services
Thomas F. Geiler,Director
• BARNSTABLE,
9 . � Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: In
Designer: fan 1 Installer: cl1 sai C_
Address: (g Address:
On was issued a permit to install a
(date) (installer)
septic system at p,%Jbased on a design drawn by
(address) I
dated �_ a
esigner)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-built by designer to follow.
�H:Of AMgS
nstal er's Sig a re) o CARVE
E.
u SHAY
No; 1181
(Designer's Signature)- (Affix De re)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVIS N. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
N
Q:Health/Septic/Designer Certification Form
Commonwealth of Massachusetts • a �_ /`3 T"
:a=l Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Winshore Dr
c
Property Address :"
Stephen Siminski
Owner Owner's Name /
information is required for every Hyannis MA 02601 11-8-16•
page. City/Town - State Zip Code Date of Inspection W
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector: s
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes _❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority -
11-8-16
I spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
zti id
Commonwealth of`Massachusetts y
'r Title 5 Official Inspection Form
�f�;I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r ;,
4 !y 125 Winshore Dr
F SS
t J
Property Address
;�, Stephen Siminski
Owner I r; Owner's Name
information is Hyannis MA 02601 1 T-8-16
required for every y �
pages City/Town State Zip Code Date of Inspection
`A B. Certification (cont.)
Inspection Summary: Check 'A,B,C,D or E/always complete all of Section D
A) System Passes:- -
ti
® 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:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
x the Board of Health,will pass. ,
Check the box for"yes", "no" or"not determined".(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y., ❑.N - ❑ ND (Explain,below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
i
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection-. Form
s; it Subsurface Sewage Disposal System Form Not for Voluntary Assessments
as;
125 Winshore Dr
Property Address
Stephen Siminski a
Owner Owner's Name
information is required for every Hyannis MA 02601 11-8-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.) , -
El Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
` pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage'backup or r.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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
{ f Title 5 Official. Inspection Form
�' Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Winshore Dr
Property Address
Stephen Siminski
Owner Owner's Name
information is required for every Hyannis MA 02601 11-8-16
page. City/Town . State Zip Code Date of Inspection
B. Certification (cont.) ,
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑, The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
_Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes or"No"to each of the following for all inspections:
Yes No
. - R
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
f Title 5 Official Inspection Form
: I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Winshore Dr
Property Address
Stephen Siminski
Owner Owner's Name
information is required for every Hyannis MA 02601 11-8-16
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of_cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion'of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
- _ and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.•
❑ ,� ® The system fails. I have determined that one or more of the above failure
criteria exist as described in1310 CMR 15.303,therefore the system fails. The
r . , system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
- _ Commonwealth of Massachusetts
al Title 5 Official Inspection Form
li;4 Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,.p,$�✓' 125 Winshore Dr
Property Address
Stephen Siminski
Owner Owner's Name
information is required for every Hyannis MA 02601 11-8-16 '
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system,components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
r ❑ ® 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) '
T ,
r® ❑, , 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 maintenance of subsurface sewage disposal systems?
proper 9 P y
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existinginformation. For example, a Ian at the Board of Health.
P P
,. Determined in the field (if any of the failure criteria related to Part C is at issue
® ❑ approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
W Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
..�,3!• 125 Winshore Dr
Property Address
Stephen Siminski
Owner Owner's Name
information is required for every Hyannis MA 02601 11-8-16
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes E No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 11-2016
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts F t
r f Title 5 Official Inspection Form
"A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Winshore Dr
Property Address
Stephen Siminski
Owner Owner's Name
information is required for every Hyannis MA 02601 11-8-16
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: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for um in :
P P 9
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
:N Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
125 Winshore Dr
Property Address
Stephen Siminski
Owner Owner's Name
information is required for every Hyannis MA 02601 11-8-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and-source of information:
2004
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan): ,
Depth below'grade: 12"feet
Material of construction:
❑ cast iron' ® 40 PVC ' ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 6"feet
Material of construction:
® concrete ❑ metal ❑ fiberglass El-polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
Sludge depth:
12"
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection Form
W. Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments,
a�
125 Winshore Dr
Property Address
Stephen Siminski
Owner Owner's Name
information is Hyannis MA 02601 11-8-16
required for 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
20"
Scum thickness
1"
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
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction: f
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
I
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
tal Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
•:,_�_;;�� 125 Winshore Dr .
Property Address
Stephen Siminski
Owner Owner's Name
information is
required for every Hyannis MA 02601 11-8-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
concrete metal fiberglasspolyethylene other(explain):
❑ ❑ ❑ 9 ❑ ❑
Dimensions:
Capacity: ,
gallons
Design Flow: I:, I 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
R+ ,� Title 5 Official In m spection For
�� Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
,f!✓ 125 Winshore Dr
Property Address
Stephen Siminski t,
Owner Owner's Name
information is required for every Hyannis MA 02601 11-8-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from field.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R; VA Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments .
125 Winshore Dr
Property Address
Stephen Siminski
Owner Owner's Name
information is required for every Hyannis MA 02601 11-8-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 5-Infiltrators
❑ 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.):
Infiltrator leach field in good working order with no sign of back-up into d-box or surrounding stone.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection. Form
fI
' If;., Subsurface Sewage Disposal System Form Not for Voluntary Assessments
125 Winshore Dr
Property Address
Stephen Siminski
Owner Owner's Name
information is required for every Hyannis MA 02601 11-8-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on-site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I
Commonwealth of Massachusetts
:a1 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments '
125 Winshore Dr
i 9 TS
t !
Property Address
Stephen Siminski
Owner Owner's Name
information is required for every Hyannis MA 02601 11-8-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately `
C
0- -JO
d
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17
Commonwealth of Massachusetts
:a=1 Title 5 Official Inspection Form
f
+ ,r+,
,:-� Subsurface Sewage Disposal System Form Not for Voluntary Assessments t
125 Winshore Dr
Property Address
Stephen Siminski
Owner Owner's Name
information is r
required for every Hyannis" MA 02601 11-8-16
page. Cityfrown '. State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, lease see Report Completeness Checklist on next page. `
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�.I
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
l jar
J;!y 125 Winshore Dr
Property Address
Stephen Siminski
Owner Owner's Name
information is required for every Hyannis MA 02601 11-8-16
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
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NO
WILL•.IAM F. «VFL.D
pr
C' 1\L.EIv�k1 Tf:UDlr!?\F
Governor i n tirre'can
ARGEO PAUL CELLUCCI B. s9' t IIS
Lt. Governor - - - •--- Comr csioner
SUBS(MIAC1 SiWA(;E DISPOSAI. SYSTEM INSPECI ION FORN,1-� TOWN OFBARNSTABLE
HEALTH DEPT.
VAR I' A �� '.
CER IIFICATION
'*•
Property Address: 12 5 Windshore Dr. Hyannis Address of Owner: Y
Date of Inspection:9_18_98 fit different)
Name of Inspector: Jamie Bissonnette
I am a DEP approved system incpe(Im pur%taanl Ili Se(liim 15.340 of Tille 5 f310 CMR 1a.00M
Company Name: JLB Title V Inspections, Inc.
Mailing Address: 70 Pickens St. Lakeville MA 02347 _ T__ __
Telephone Number: 508-947-7735
CERTIFICATION STATEMENT
I certify that I have personally inspected Ilie wv' ,;age dlspor ;11 rslem al taus addwss and th,ol the inlorrnauon reported below is true, accurate
and complete as of the time of inspection. 1 he ire:pr'(ann ',%.Is perronned based can niy trauutag .111d experience in the proper function and
maintenance of on-sile sewage disposal sy<-iv m�. 'I hr• .t,•ni
x 'Passes
_ Npoi s Filr6wor 6, ii'r I-,;I iwwovun! Auihol11v
rails
Inspector's Sig .1 _ Date:
The System Inspector shall submit a'copy of Ilus inspection wport to the Approving Aulhonly 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 systemtowner shall submit.
the report to the appropriate regional office of 1111' Departn,cnl (if Environmental Protection. 'I he original should be sent to the system owner
and copies sent to the buyer; if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D-
AI°'SYSTEM PASSES:
£. -
yes I have not found any information which indicmrs that file system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicalf.41 below.
COMMENTS: The system was_in Qotxi working otder at the time of inspection. 'the system does not violate
y gf the failure criteria of TitleyV atethe time of ins_ction.
BI 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 appioved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y, N, or ND). .Desoike basis-of determination in all instances. If"not determined", explain why not.
The septic.tank is metal, unless the owner or operator has tarovided the system inspector with a copy of a Certificate of
CornplianceJaitached) moicaling that 0w lank was installed within twenty 120) years prior to the date of the inspection: or
the septic lank, whether or not invi al, a< (jacked, structurally unsound. shows substantial infiltration or exfiltratron, or tank
failure is imminent. The ssu•m will pass inspection if the,exiting sepias tank is replaced with a conforming septic tank
as approved by the Board ill I Icallh.
fee%r rod 04/25/91) r'ayo 1 of 10
SUBSURIACE SLWAG[ DISPOSAL SYSIEtI INSPFCIION FORM
PART A
C_ER11FICATION iconlinued)
Property Address: 125 Windshore Dr. Hyannis
Owner: Dave Gustison
Date of Inspection: 09-18-98
BJ SYSTEM CONDFIIONALLY PASSES (cuntnn.trdt
_ Sewage backup or bre,rknut or hir!h cl,lu( v-oler level observed n; the diSlnbutron box is clue to broken or obstructed
pipe(s)'or due to a broken, Sr,rtllr d nr uneven dlstribo(il.,n box, The will pass inspe_clion it (with approval of the
Board of Health). Descrlhn i,bscr'v.11rnn�:
brukrn p1pe(s) ;Ire rrl,l.ued
ob5lim(ion Is rl+lnoved
dtstnhulmil box IS levelly d ur n placed
The system required puwpine mow Ilion Inur timos a v('ar clue to broken or obstructed pipe(sl. The system will pass
inspection if(with approvol of the I3( ard fit Hv;)llh):
brrrkr:n pip,,:tst any rrl,I:tCr(1
U{,St11Pll(111•Iti lil n1111`d
CJ FURTHER EVALUATION 15 REQUIRED BY 11iE BOARD OI- I-ILALIH:
Conditions exist which require funher rvalumiim by thn i3o,11cl of Health in order to determine if the system is failing to protect tf.
public health, safety and the f nvnonnlenl.
1) SYSTEM WILL PASS UNLESS BOARD OF HtAITII DIIERMINI-S TW4r 11-IF SySTFM IS NOT FUNCTIONING IN A MANNER
Cesspool or privy is wnhln 50 IPot nl a suria(e. water
Cesspool or privy is within 50 feel of a b(nctermy vebetale(I wealan(.l or a Sall marsh.
2) SYSTEM WILL FAIL UNLESS TH[ BOARD Ot' 11FAL I (ANT,) PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A tv4ANNF.R THA F PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic_ tank .ind Soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
The system has a septic lank and soli absorption system and the SAS is within a Zone I of a public water supply well.:,.
The system has a septic Iank 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 absowlion 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 (hat
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. Method used to determine distance (approximation not valid).
F
3) OTHER
(rovined 04/25/97) Vega 2 of 10
SUf MAVACE SL%ti'AC;L WSPOSAL SYSILM INSPECTION FORM
PART A
(JRTIIICATION iconlinuedl
Property Address: 125 Windshore Dr. Hyannis
Owner: Dave Gustison
Date of Inspection: 09-18-98
DI SYSTEM FAILS:
You must indicate either "Yes" or „No" ,is to rac:h of dw hillo-111PI
have determined that the syster„ —0,iles oru, ()I more of the following fa,ILlrt,' rrltena as defined in 310 CMR 15.303. The h.isis
for this determination is identitied hrlow. 'I Ill. Noanl of Health should lie contacted to determine'' what will be necessary Ip correct
the failure.
Yes No
Backup of sewage into ia1 illy' or kN-Win t o'nou"c"t dui;• In all overloaded of clugged SAS or Cesspool.
_ Discharge or ponding of rilluvnt I, nu Snllar! ire ihrt g,00nd or surface wators due to an overloaded or clogged SAS or
cesspool.
Static liquid level ui th(,dlclrthtilioll III)X .lhrnn vudel nlvert (Joe 1(i .It, overloaded or clogged SAS or cesspool.
Liquid depth in tesspoO is Ic- Ih.,n r," hulOW nrvrrl or ava,lahlo volume Is less than 1/2 day flow.
Required pumping mum Ihan 4 tuni t in thr 1w.1 year NUT du(• to clogged or obstructed pipets).
Number of limes purllped ,
Any portion of the Soil :\hscrltaiun wr,iom, (,css)wol or privy 15 below the high groundwater elevalfon.
Anv portion of a cosst)(11 l w pllvv 1S wilhl'l MO Of a scrflaei` kvat('r stipply or IribLII;:rV to a SUrfaCn W,'Ilrr CUpply
"'ny Portion 01 o C.C✓✓�:n'I ., i; .. ,.,rh .. .. 'I ,.r ir.,rll, 1,nll
Any portion of a cesspool or privy is within 50 feet of a priv,ite water supply well.
i
,
_ Any portion of a cesspool it, ptivy is I,,cs Ih:m 100 feet bill greater than 50 feet from a private water supply with no
acceptable water quality analysis. 11 the well has been an.lIW;ced to he acceptable, attach copy of well water ,inalysis for
coli(orm bacteria, volllile organic cornpokinds, anurlonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
You must indicate either"Yes" or "No" as to each of tho Inllowiny.:
The following criteria apply to large sysle.rns it, addition to the crilefia :above:
The system serves a facility with I design flow of 10,000 ylid or greater (Large System) and the system is a significant threat to
public health and safety and (lie envirnnn'icitt because one or more of the following conditions exist:
Yes No
_ the system is within 400 feet of a smfai(• drinking water supply
the system is within 200 feet of a tributary it)a surface drinking water supply
the system is located in a nitrogen wiv;itive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone It of a
public water supply well)
The owner or operator of any such system shall briar; Ilse system and facility into full compliance with tile groundwater treatment program
requirements of 314 CMR 5.00 and 6,00. Plrase collsull the local regional office of the Department for further Information.
(revised 04/25/97) - Pays 3 of 10
SUBSURFACE SEWAGE DISPOSALSYSTEN1 INSPECTION FORk4
PART B
CHECKLIST
Property Address: 125 Windshore Dr. Hyannis
Owner: Dave Gustison
Date of Inspectiun: 09-18-98
"Check if the following have been done: 1'uo nnrat inrlir,d%• erilrer "Yes" or "No" ;is to vac h of the following:
Yes No
X _ Purnping information was provided by the Owner, Occupant, or Boan.l of Health.
X _ None of the systern comirof wills Ir;rve been wirlmed for at least Iwo weeks and the syslern has been receiving normal
(low rates` during d,,,tt pranlyd, Large volumes of w,:iler have not been introduced into the system recently or
as part of this inspection.
X _ As built plans have been iihianted raid exaniined. NOU3 if Ihnv are not available woh NIA.
.r
X The facility or dwelling way inspected for signs of sewage back-up.
X _ The system does not ircr'rvr' nUrt-sanitary or industrial waste flow.
The site was inspected for s trans of breakout.
X _ All system components, exclmjin,p, the Soil Absorption System, have been located on the site.
baifres fir tees, la i'ieli.'u i cfhrtli., niii, , icpu, Ur s,ud.c, icp C s:.unl. _
The size and location of Ili(,, Soil Absorption System oil the site has been determined based on: .
X _ The facility owner find ocrupanls, if differeni from owner) were provided with information (.)it the proper maintenance of
' Sub-Surface Disposal System.
X _ Existing information. Ex. Plan of B.0.1-1.
X_ Determined in the field Gf;any of Ihr; iaihire criteria related to Part C is at issue, approximation of distance is
unacceptable) 115-302(3)(1))1
r,
(revised 04/25/97) Page 4 of 10
rl
,a
t SUBSURFACE SEWAGE DISPOSAL.SYSIGM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 125 Windshore Dr. Hyannis
Owner:Dave Gustison
Date of Inspection: 09-18-98
I LOW CONDITIONS
RESIDENTIAL:
Design flow: 3 3 0 g.p•d•/bedroom for S.A.'.
Number of bedrooms: 3
Number of current residents:2
Garbage-grinder(yes or no):.n�o
Laundry connected to system (yes or nu): Y e s
Seasonal use(yes or no):no
Water meter readings, if available (last two 121 year nslctr iFvd):
Sump.Pump (yes or no): n o
Last date of occupancy:
COMMERCIAUINDUSTRIAL•
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_ r
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system ivc% ter no)_
Water meter readings, if available:
OTHER: (Describe)
Last date of occupancy:
GTNFKAI_ INFORMATION
PUMPING RECORDS and,source"of information:
The system was wnped, 2 weeks and 2 days prior to pt-Ming.
-System pumped,as,part of inspection: (yes or no) n
If yes,volume pumped: gallons
'Reason for pumping:'
TYPE OF,SYSTEM ___...
ems; 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. Copy of up to date cunhactf
Other
APPROXIMATE AGE of all components/ daie installed (if krwwn) and source of information: 19 7 7
Sewage odors detected when arriving at the site: (yes or not no
(r*vimed 04/15/97) Pape 5 of 10
is
' '; `' "'':' 5UBSURFACE SEWAGE DISPOSAV SYSTEM INSPECTION FORM ` °t
"PART,. a a
5YS'IEiM INFORMATION (continued)
Property Address: 125 Windshore Dr. Hyannis ,
Owner: Dave Gustison
Date of Inspection: 09-18-98 #
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 3
Material of construction; cast iron _ -10 VVC _ oilier loxpl;un)
Distance from private water,supply well or suction bnr
Diameter
Comments: (condition of joints, venting, evidence of leakage, oc.)
SEPTIC TANK:g
s (locate on site plan)
Depth below grade: 611
Material of construLttoni x concrete _metal _Fihcrv'la�s _polvetltv(ene—other(explain)
If tank is metal, list age Is age conlirmed by(.enuicate of Compbance _(Yes/No)
;.Dimensions: 8x5x4.'_
Sludge depth: I"
21911
Scum thickness. 2"
Distance from top of scum to lop of outlet tee or ba(lle: _8"
•Distance from bottom of scum to bottom of pullet We or baffle:
10"
How dimensions were determined: ueasure pole
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation 10 outlet invert, structural
integrity, evidence of leakage, etc.) The tank seemed to be in good condition. there were no signs of any leaks.
,,The structural integrity looked good. The outlet tee~ wasp, in good condition:
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction: _cancre(e`metal __Fibeiglass _Polyethylene_oiher(explain)
Dimensions:
Scum thickness:
:.Distance from,lop of scum to top of outlet tree or baffle:
Distance from bottom of scum to bottom of outlet tech ix baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and o.1110 tees or baffles, dewh of liquid level in relation to outlet invert, structural
'integrity, evidence of leakage; etc.) _
(Tovised 04/25/97) of 10
.t ..
4
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
5YS I FM INFORMATION Wontiiwedl
Property Address: f '
p Y 125 Windshore Dr. Hyannis , .
Owner: Dave Gustison k
Date of Inspection:09-18-98
TIGHT OR HOLDING TANK: frank mini he pumped prior to, or at limf, of iospvcijolo
(locate on site plan)
Depth below grade:
Material'of construction: —concrete _rnetal _Fihervl,is� _11olyethylene _wlic.nexplami
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level: Alarm in working! girder
Date of previous pumping: .
` Comments:
(condition of inlet tee, condition of alarm and flo.il swltchc•�, f'tr_.)
DISTRIBUTION BOX:x
(locate on site plan) —
Depth of Liquid level above outlet invert: Oil
Comments:'
(note if level and distribution is equal, evidence of solids c:uryover, evidence of leakage into or out of box, etc.) The D-box was working
. .,properly and had no sign:of any carry over from the tank. There was no sign of leakage into`the d box. f' r
,PUMP CHAMBER:_
'(locate on site plan)
Pumps in working order: (Yes or No) _
Alarms in working order(Yes or viol
"Comments:.
(note condition of pump chamber; conclitio oumps and appufte,nances, etc.)
r
(revised 04/25/97) Page 7 bf 10
r SUBSURFACE SUWAGE DISPOSAL SYSTEM INSPECTION FORM
g PAR`F C .
SYSIFM INFORMATION (continued)
Property Address: 125 Windshore Dr. Hyannis
4• is '' 1
Owner:Dave Gustlscin
Date of Inspection: 09—.18-98
SOIL ABSORPTION SYSTEM(SAS):X
(locate on site plan, if possible: excavation not rer,tuued: but rn•ry he aur.rrox1nr..,ted I,v non-intrusive methods)
If not determined to be present, explain:
Type:.
leaching pits, number- 1
leaching chambers, number:_
leaching galleries, number:
leaching trenches, number,le-ngth:_ ^
leaching fields, number, dimemu,nti:_
overflow cesspool, number:
i Alternative system:
Name of Technology:
Comments:
(note condition of soil; signs of hydraulic failmr, Irvel of ponding, condition of vegetation, etc.) r
"There was no sign of any type of failure The system was working good at the time of inspection. _
CESSPOOLS: _ tc
(locate on site plan)
Number and configuration:
`Depth-top of liquid to inlet invert:
;F Oepth',of solids layer: __ s
Depth ofscum layer
Dimensions of cesspool
Materials as of construction:
Indication of groundwater'''
inflow (cesspool must be pumped as part of inspe(tion)
Comments:
(note condition of soil, signs of hydraulic failure, level of pondinP, 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.)
(revised 04/25/97) Pane A of 10
0
Slfl3SURI`A(f 5i%VACl DISPOSAL S1'Sli'm INSPFCIION FORM
PART C
SYSTTM IN17ORNAA11ON Iconlinuedt
Property Address: 125 Windshore Dr. Hyannis
Owner: Dade Gustison
Date of Inspeclionog—18_98
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties lu at least two permanent rI Irvr nr I,uulnlackt or brnc-hmalks
IOLate all wells within 100' ILoc.ur -hrcr, mildir watvr 511p iv corms Into houwj
rack d d s ��
I
r iI
Corw(El TUL
1
I
NOT TO sC US
(revised 04/35/97) - - Vngw 9 0£ 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPL XTION FORM
PART C,
SYSTEM INFORMATION.(continued)
r'
Property Address: 125 Windshore Dr. Hyannis
Owner: Dave Gustison
Date of Inspection: 09-18-98
Depth to Groundwater _ Feel �' O �"i OLX 0 a
Please indicate all the methods used to determine IIigh Groundwater Elevation:
(�Obtained from Design Plats on record
Observation of Site (Abutting property, observation hole, hasement sump etc.)
Determine it from local conditions
Check with heal Board of health
Check FEMA Maps
Check pumping records
Check local excavators. installers
Use USGS Data
1 oµ• words �. til;�;I na a.,. I1�.•k . .,.1;1. [_Inv " hn Completed"
Des�.ribe in you. own orc., how ••oa es:a..._.,,. ... . ...,. .. a:e: ..,.. aav::. "Must .:_
�er c TJOC m Ati o11.
J
t
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DATE:
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.. .r /�=�' .T►lc::, c�F+=S C"�, 5�-lore APPt._1G.e."-r
C-T U e.
LOCATION SEWAGE PE MIT NO.
V.ILLACE
r
INSTALLER' NAME & ADDRESS
6
I
k'UItDE R OR OWNER
DATE PERMIT ISSUED � .2
DAT E COMPLIANCE ISSUED7� -
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•............. Fss.... ......................
No..
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliratiun for UiipuuFal Workii Tunilratrtiun Frrutit
Application is hereby made for a Permit to Construct ( 1-1-or Repair ( ) an Individual Sewage Disposal
System at
---- ...._... ....���_v.�--' e -------------•-----•-•-- --•----"---- .....................................................
Location-Address or Lot No.
Owner Address
W ............. q....._. .. _.A....................................... ................................ ...........................................
a ✓✓✓ Installer� Address
UType of Building Size Lot__.14.---tr ....Sq. feet
Dwelling—No. of Bedrooms.......3................................Expansion Attic ( ) Garbage Grinder )
PLI Other—Type of Building ............................ No. of persons__---_______-__-____.___---- Showers.( ) — Cafeteria ( )
Otherfixtures ,- ` -------------•-----------------------------•--•-----------•----------------------------•-•------------•••-•.----------------------
W
Design Flow.............................................gallons per person per day. Total daily flow.. ; sue...._...._..__..._..gallons.
WSeptic Tank—Liquid capacty............gallons Length................ Width................ Diameter________-___-.__ Depth................
x Disposal Trench—No. .................... Width..................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No,l oA Diamete _Aft-.I pth below ' et.................... Total leaching area.. sq. ft.
Z Other Distribution box ( ) Dosing tank ( r0' 50 7-7
'-' Percolation Test Results Performed by_______ ........—_...___..�A. ..G'?� Date....1.Q.-3d--?..........__.
aTest Pit No. 1---_............minutes per inch Depth of Test Pit.................... Depth to ground water________-____-__-_-____.
G Test Pit No. 2................minutes per inch Depth of Test Pit.............._..... Depth to ground water........................
O Description of Soil.............................. - -2........ 4�cs.� - ..... -- .
c, -----------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable._____________________________________________•..._.._____.__...._..........._...._.._..._._.__.
..--•-.-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITU 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health01
A Sign �i y Date
Application Approved By•-••-------••-•�--- ..?dV,6444 ••---•. oe.............. .....
Date
Application Disapproved for the following reasons---------------•--•------ ---------------------..........................................................
---------------------•-----...-----•-••-•----•---------------•••-......-•--------.......---••------••-••-----------------------•--•---••----••••••-----------------•--------•-••----------•-•--•--•--•--
Date
Permit No......................................................... Issued_...- - d
-------- --•---- .....................••----------------•---
Date
-17
No.--....... ........ FEB.. ........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Z040-iU...........OF- ........................................
is
Nliptiratiou for Uhipwial Works Tomitrurtion "amit
V
Application is hereby made for, a Permit to Construct or Repair an Individual Sewage Disposal
System at
..... ......At.......................
L tion
_,;,Address or Lot No.
..................................... .......... ------- ----i ..........................................................
----------------....
Owner Address
.................................................................................................. ..................................................................................................
lns�aller Address
g Size Lot.ZSf,-�9."-"....Sq. feet
Type of Building
Dwelling—, No. of Bedrooms....... ..................................Expansion Attic- Garbage Grinder 410)
PL4 Other—Type o ul difig ............................ No. of persons.....:..................... Showers Cafeteria
I Other fixtures
. ...................................................................................................ftr5.......................................
Design Flow.............................................gallons per person per day. Total daily flow------ ...........o.........gallons.
Septic Tank—Liquid*capaci
ty............gallonss Length................ Width................. Diameter-_--- ......... Depth........_...._..
Disposal Trench—No..................... Width Total Length.................... Total leaching area.................��,gq. f t.
------------ ;K Seepage Pit No/ 01;7W--' Diameta-f4-.A-4c, epth below 'nlet.................... Total leaching area. A' ft.
4%0- 7 7'
Z Other Distribution box Dosing a ell
Date- 'a- Zo
Percolation Test Results Performed by-------..... .. .........7!7:........ ---------- ........................0.............
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water..___.__.._._...........
Test Pit No. 2................minutes per inch Depth of Test,Pit..._........__...... Depth to ground water_.__....._.........__...
...................
0 ----- ........ ------Description of Soil ........ .................................. . .. ..
77------- --------------V
U ........................................................................................................................................................................................................
W -
................................................................................................................................................................ ..............................
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
......................................................................................................................................................................4...............................
Agreement
9 rpent:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T I T 11 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health
.... .... .............
Qe
ZVI :4 -7
C�,
Application Approved By............................. ........
............................. ...... -------D a-be-------------
Application Disapproved for the following reasons:..............................................................................................................
.................................................................................... ................... ..... ------------------------W ------ �`------------------7---------
Dife,
Permit No......................................................... Issued.......�5
Date
THE COMMONWEALTH OF MASSACH-USETTS
BOARD OF HEALTH
............ ...................0 '.,.07 .....f l....................................
.............. ...
THIS IS rTE�R?!� That-'Ahe Individual Sewage Disposal System constructed (A01-or Repaired
by..................... .......... ....... ......................................................................................................
r .... , -------- ---------
at.Du...jr C vr C,44',-,
................!�� .......:.i....i.. !0 Sri................................................................................................
has been installed in accordance with the provisions of T r�-�F 5 of The State Sanitary Code as described in the
2 Ic...... dated_-.!_`-...2-17-27..............
application for Disposal Works Construction Permit No ...... ..... . ..............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A OUARANTEE THAT THE
SYSTEM WILL,FUNCTION, SATISFACTORY..,,�,;
DATE..........A..—.14.... K�.................................. Iftspector-.-,A0&--Z/A4k ----------
.....
THE COMMONWEALTH OF,-MASSACHUSETTS
BOARD OF HEALTH
................
g7l, ............0 F.. ........f.........
2 ........................
No...................% FEE.........................
A-A
Permission is hereby granted............... ..........................................i
............ ...................................................................
to Con§tLu jr. an Individualewage Disposal System
atNW. .1..&...W� a ........... f ------------------------------------------•..........................................
Street
as shown on the application for Disposal Works Construction Per 't o ..... Dated.._.12- ;2 9�-77
......................................
.................. ..........................q-1XfA--Z*...........................................
DATE.....................................:......................... Board ofofealth
.................
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
C��51G1�: 'DQ.TA ►� .
�IL1Gl� trAMtl_�f =•. 3�31�iZDC>�1/� . . `
L10 GA273AG7r q 6R,1 QD�lZ 4
tadlU-4 FLOW S30 G-p- ' ..
5 'IC 330.r ISO % • 5 6 P..Lj
U4;4- l 00C:�j C=A L f
t�)ISP054'L PIT uSF- loco GAS..
= u+.
sty-WALL AREA l50 S.F.
SF ,c 'Z.S + 3 IS G.P.D.
8�1-rz�Nt ,o Qom._ ST-.
SD ss'.
TOTAL .'V ESSIGN II 42S 6.RD. ' : ;`} ` /7
OT&L bQ1 L�f
T 1=LD W s 33p 6.PD ! ' 4 /G f ," TAdr
t {
rMfZGDI.d,T10tJ CZATE•: 1"lu I_MIu' OQ LE'JS ` 10 • . .` -
f + �
``T,k OF/}Ste'\ ' ii ? f ...,4�j 0�
RICHARD o ALAS
N
BAXTER v v J ES
Nc 0
4
8 1G0 • j
GtySTf\P
�roU SU �� ` /OCtgL •1� �.C/
It
Tor F'wo a too.o
LO AM:t �" oB Ioofl 1w. 'A
* 4'pv 1w. GAS.
2 S�Bgr 'box �d Sepne 10 4
11JV. T-o N K
1I 1000 45� ,wv. 1►►v. i, {
�I� a GAL.. .
LH 'A OF
PIT
WA%1<D t { {
1 STON�z 1 6
r1Z.� -1 L�
1Z ASS LoCAT101-4 14k 0 4 14
1_lo ScA.t..�- CAS. — + 4n bATM lt- 30 l'I
Igo VJATE� �eO�o's� ptA►.1 R�1=CRE►.1G�
GG R T 11=�( :Tel A T T N bw�t.c.l IJ L 51.1aw
t-1�,P.L=bIJ G��VIPLV'g W 1TIA THE: 51DE..LI�� LoT L
auv Sc'r�nclG �c4UlQEM�uTS 4F TNC, • • .
g 7'cwy o�'8A21J;TI�P LAW:, Co,)vT 3`1CoGG.
XTG R.
z REGlS tttZ>=D "wG 5U2V&Y0V-4
T1-115 pl./f►1.1 1%, L.1oT BA-SM0 U�,.1 AN OS?E2VIt,.t.G o Ib(ASS•
11JS"C�'UMC?WT �iUl \/t ( ;� Tt{L: UF1= ,r-xe, et4r1ujLaD APPLIGAJJ-r
A�, l,•( t b� 'Dot/ Co.
_ _._._w.__._.._ ...._w__.,_.._....._._.. .._.._........ _.__.._.._.....__._
�huse
10' min. from 'NOTE: ALL PIPES ARE TO BE 4" SCHEDULE 40 P.V.C. SECTION A -A Nt auner Fix FROM1t+eExisting Foundation to septic tank SEND Schedule ((o VC w hortodInches toe) PROF ILE VIEW OF ADDIT;ON TO LEACAFING SYSTEM o�Culm eox swui eE �
Schedule 4b PVC w
a t f
fGt,QFtod Odor Filter " BET 1.M1 FOR AT LEASE 2 FT, i2' CONCRETE COVER
TOP OF FOUNDATION ELEV. 100.00 {Assumed) w seanh � 3/4• to be
11 8"2"t j2 Washed P
Septic end (rushed St.
Grade over Tvik - 99.00 Grade ow D-Box.- 97.00 ovr SAS- 97.Qo � MIOet1 - OUTM
� �►1r�yAanl- d{ �� f ( a
::4_
S - 0.02
--- 3s• a e i r;
ounET 12• saEr r Ii +s r
3 OIST. BoX 0 3 limdp,mn Cattif Top Load-EMv. •Al2S { fr`` Q r e s j F:.t.'Z ry1
1 14' 1,00 EXIST.
S.O.O' or Great: t
p S 0.01'
FROM E)IST.FBUNeAT110l1 w y-I SEPTIC TANK Q PK tbpt ENectiw Depth 15 5` 4• - SCH. 4C1 T 1.7s• d a( ( c^ /tt f C f
p H-10 *a. 01 � '� 5 lhltts � bt?5' � 30
Uri PLAN SECTION CROSS-SECTION
a0►K RE1E FULL FouNM i m g i 0.83' (10 inches) 3�
rn -
SYSTEM PROFILE RL in.o1 3 4•-, 1 f
� 1 /z" o o r � 37.i?5 3 HOLE H-10 DISTRIBUTION BOX ! ��� t r
Not to Sale compacted stone c g t RM,1 EffeciJYe Ler,pth NOT TO SCALEp� ;
' 4' 4' R SOIL ABSQRPTI SYSTEM (SAS) s �+ • sMo t I
a In.of 3/4•-1 1/2' g 10F INFILTATRQR HIGH CAPACITY (H-20 LQADING)/ GEQRGE ❑'BRIEN
GENERAL NOTES
oGmp°`ted stone Effective Width 8(0rOd Y OR EQUIVALENT Not to Scale
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6' BELOW GRADE ( ) 1. Contractor is responsible for Di safe notification
o Bottom of Test Observed
1'E1ev.�BfIBB g
No Groundwater Observed 0 120 ,$ NOTE: OVERALL HEIGHT OF INFILTRATOR IS /8" /EFFECTIVE HEIGHT IS 10' and protection o all underground utilities and pipes.
- - 2. The septic tank o tip distlylion box shall be set
level on 6" of 3. 4 -1 1 2 stone.
3. Backfill should be clean sand or gravel with no
stones over 3" in size.
4. This system is subject to inspection during installation
by Carmen E. Shay - Environmental Services, Inc.
5. The contractor shall install this system in accordance
PERCOLATION TEST with Title V of the Massachusetts state code. the approved plan
-05
OS and Local Regulations.
Date of Percolation Test: AUGUST 2, 2004 �`
I 6. ff, during installation the contractor encounters any
Test Performed By. CARMEN E. SHAY, R.S., C.S.E. � ' soil conditions or site conditions that are different
Ab
Results Witnessed By. WAIVER (per Barnstable B.O.H.) i from those shown on the soil log or in our design
SHAY ENVIRONMENTAL SERVICES, INC, _ 1197.81 i installation must halt & immediate notification be
Percolation Rate: Less Than 2 MPI 0 36" Assumed made to Carmen E. Shay - Environmental Services, Inc.
i i 7. No vehicle or heavy machinery shall drive over the
LOT #6 i� i� septic system unless noted as H-20 septic components.
6. Install Tuf-rite gas baffles or equals on all outlet tee ends.
f5,459 Sgtaare Feet t/- 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
Test Hole 10. All solid piping, tees & fittings shall be 4" diameter
No. 1 Schedule 40 NSF PVC pipes with water tight joints.
DEPTH SOILS ELEV. i 11. Municipal Water is Connected to ALL OF The Residence and Abutting
i
r 0 Sandy 97.00 / Properties Within 150 Feet.
Loom
THE PROPERTY LINES ARE APPROXIMATE AND
, �
10 Y 3/2 i Foiled
0"-8• 96.25 COMPILED FROM THE SURVEY PLAN GENERATED BY
A
Leach Pit , STANLEY R. SWEETSER OF HYANNIS, MA
Sandy TEST HOLE #1 ,� ENTITLED " PLAN OF LAND IN BARNSTABLE, MA,
Loam ELEV.= 97.00/ MA", DATEDJULY 11, 1973, PLAN # 37666-A SHEET 1
10 YR SA / 7.25 LOT #7 & THE DEED DESCRIPTION ( C121827)
e•- 36" B. 9400 LOT #5 1 z:1... . <:
,.: i, , IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
Sand S. S• , Tit THE SEPTIC SYSTEM INSTALLATION.
• EXISTING
24 r s/a -3 =* �` • D � • 2 GARAGE EXISTING LEACH PIT TO BE PUMPED OUT AND
36"-t32 C, 88.00 1 , 4a.`" �' D-Box
REMOVED TO FACILITATE NEW SEPTIC SYSTEM INSTALLATION
.. NOTE.- ANY-STRIPPED-OUT SOIL CONTAINING i-EACHATE
4" PVC +i j EXIST.
pt c Ta gal +++ FROM THE EXISTING LEACH PIT TO BE DISPOSED
' VENT i 0 + + OF AS PER BOARD OF HEALTH SPECIFICATIONS.
2 r ++ +� NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY
++ +++ ASSESSORS MAP 271, PARCEL 137
i DECK ++ +
++ ASPHALT , LEGEND
+ DRIVEWAY 1
Pere #1 I EXISTING ++
Depth to Pere: 36" to 54" z_ BEDRoo1[ + DENOTES PROPOSED
Pere Rate- Less The 2 MPI + 1 104X 1
HOUSE + , SPOT GRADE
Groundwater Not Observed r I ++
No Observed ESHWT 1125 DENOTES EXISTING
PROJECT BENCH MARK I '
ADJUSTED H2O Elev. = None TOP OF FOUNDATION i +, 1 X 104.46 SPOT GRADE
ELEV. = 100.00 (Assumed) i
i++ ++ l�+ pL PROPERTY LINE
PROPOSED CONTOUR
- - - - - -97 EXISTING CONTOUR
+ +
I +2-18• DIAh1. ACCESS MANHq.ES DEEP TEST HOLE &; '� � 1
I
�g,04 PERCOLATION TEST LOCATION ON
•.T 6 FOOT STOCKADE FENCE
41
OUTI ET _ ., o l PLOTTHE ACCESSCOVERS FOR THE SEPTIC TANK p = 80.0O \� l P LAN
H OISTRIBUIION BOX AND LEAC NG COMPONENT R �P
3 -+- s�- -• = 1r A,B I�T��°Nw � °� ° OF PROPOSED SEPTIC SYSTEM UPGRADE
STEEL REINFORCED PRECAST CONCRETE p� PREPARED FOR
PLAN VIEW INSTALL TUF-nIE GAS BAFFLES OR EQUALS y O F°
3-24• REMOVAR.E COVERS J 1�` M R. M I C H A E L HOPPER
AT
3 mh dearance
# 125 WINDSHORE DRIVE
etlET
WT1 m-r 2• mti. hdt to our ,r "owH YA N N I S MA
Uqukf level ET
liar,mk 7
s -r I- =~S' -r Design Calculations
i El
b o•IN ' Liquid depth � o� PREPARED BY:
1_ - Number of Bedrooms: 2 Equivalent to 220 Gal./Day (330 Got./Day Min. per Title V) r/� J�/��( �T C uA
w Q s LeachiGarbang Capacity
y Proposed: ( ) N V L'1 R Il is 1 ►' E. !J!l 1`� Y
Leachin Ca acit Pro osed: 330 Minirrlum Min. Per Title V
•<• ..� :•,::,: - _... i Septic Tank - 2 x 330 Gol.
•B'-O• 4• -10• - /Days 660 USE EXIST. 1,000 GAL. Septic Tank. 0 20 40 50 ENVIRONMENTAL SERVICES, INC.
CROSS SECTION END-SECTION SOIL ABSORPTION AREA: Using percolation rote of <2 min./inch $�
Bottom Area: 0.74 gal/sq. ft. x 370 sq. ft. = 273.8 gallons
'�SidewaN Area: 0.74 gal./sq. ft. x 78 sq. ft. � 58 g.�uQnB o'STE P.O. BOX 627P EAST FALMOUTH MA 025�6
TYPICAL 1000 GALLON SEPTIC TANK Providing: - 331Z1 gallons dg11lTil
' TEL/FAX : 508-548-0796
"=20 NOT TO SCALE Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING`A 0.83' (to INCHES) Er=FECTIVE DEPTH, SCALE: 1 SCALE:' 1"=20' DRAWN BY: CES DATE: AUGUST 3, 2004
TO BE USED WITH 4.0' OF WASHED STONE ON THE SIDES, .AND 3.5' OF WASHED STONE
ON THE ENDS. NO STONE UNDER. PROJECT#SD610 FILENAME: SD61OPP.DWG SHEET 1 OF 1