HomeMy WebLinkAbout0034 WOLLEY ROAD - Health 34 WOL'LEY RD., HYANNIS''"= �•:� ,
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Commonwealth of Massachusetts copy
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,.•°" 34 Wolley Road
Property Address
Peter Ford
Owner Owner's Name
information is required for every Hyannis MA 02601 October 25, 2013
- Y
page. Cityrrown State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Patrick T. Sullivan
use the return key. Name of Inspector
Ready Rooter Excavating
� Company Name
P.O. Box 89
Company Address
Forestdale MA 02644
Cityrrown State Zip Code
508-888-6055 SI 12843
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 inspections The-inspection
was performed based on my training and experience in the proper function arts maintenance o ron site,
sewage disposal systems. I am a DEP approved system inspector pursuaroni 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 f
g
October 29, 2013
Inspector's nature 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 F nn: Lurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Wolley Road
Property Address
Peter Ford
Owner Owner's Name
information is required for every Hyannis MA 02601 October 25, 2013
__
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Basement not inspected due to Radon Test in progress.
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",/2ea
not determined (Y, N, ND)for the following statements. If"not
determined," please exp
The septic tank is metalr 20 year old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substltration r exfiltration or tank failure is imminent. System will pass
inspection if the existingepla d with a complying septic tank as approved by the Board of
Health.
A metal septic tank wilpection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating thnk is less than 20 years old is available.
❑ Y ❑ ND (Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
v
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 Wolley Road .
Property Address
Peter Ford
Owner Owner's Name
information is
required for every Hyannis MA 02601 October 25, 2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is levele 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 Requ)red by the Board of Health:
❑ Conditions exist which reoire further evaluation by the Board of Health in order to determine if
the system is failing to py6tect public health, safety or the environment.
1. System will pass,anless 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
l5ins•3/13 Title 5 Official Ins
pection Form:Subsurface Sewage Disposal System•Page 3 of 17
4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,. 34 Wolley Road
Property Address
Peter Ford
Owner Owner's Name
information is
required for every Hyannis MA 02601 October 25, 2013
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 an he SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and he 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 a alysis, performed at a DEEP certified laboratory, for fecal
coliform bacteria indicates absent and a presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that n other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters
4 ❑ ® 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 Y2 day flow
t5ins•3/13 Title 5 Official Inspedlon Forth:Subsurface Sewage Disposal System•Page 4 of 17
y'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 Wolley Road
Property Address
Peter Ford
Owner Owner's Name
information is required for every Hyannis MA 02601 October 25, 2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
a ❑ ® 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 16,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is withi 400 feet of a surface drinking water supply
❑ ❑ the system is wi in 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is cated in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWP or a mapped Zone II of a public water supply well
If you have answered"yes"to a y question in Section E the system is considered a significant threat,
or answered "yes" in Section above the large system has failed. The owner or operator of any large
system considered a signific t threat under Section E or failed under Section D shall upgrade the
system in accordance with 10 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3113 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
34 Wolley Road
Property Address
Peter Ford
Owner Owner's Name
information is required for every Hyannis MA 02601 October 25, 2013
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction;
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 349 GPD
t5ins•3/13 Title 5 Official Inspection Fort:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,.. r 34 Wolley Road
Property Address
Peter Ford
Owner Owner's Name
information is required for every Hyannis MA 02601 October 25, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 1
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
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)): 2012=49 GPD2013=65 GPD
Detail:
Sump pump? ❑ Yes ® No
Current
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 3/en
): Gallons per day(gpd)
Basis of design flow(seft., etc.):
Grease trap present? El Yes ❑ No
Industrial waste holding ❑ Yes ❑ No
Non-sanitary waste discitle 5 system? ❑ Yes ❑ No
Water meter readings, i
t5ins-3/13 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
°< 34 Wolley Road
Property Address
Peter Ford
Owner Owner's Name
information is required for every Hyannis MA 02601 October 25, 2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Ready Rooter records: Pumped Oct 11, 2013
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
n
1
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 Wolley Road
Property Address
Peter Ford
Owner Owner's Name
information is required for every Hyannis MA 02601 October 25, 2013
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
System installed 11/04/1999. Certificate of Compliance on file at Health Dept
Were sewage odors detected when arriving at the site? ❑ Yes ® No
BuildingSewer locate on site plan):
( P )
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: n/a
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 9
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: 10'6"X 5'X 5'4" 1500 gallons
Sludge depth:
0"
t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Wolley Road
Property Address
Peter Ford
Owner Owner's Name
information is
required for every Hyannis MA 02601 October 25, 2013
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
37"
Scum thickness
0"
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
14"
How were dimensions determined? Tape measure and dip tube.
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet PVC tees in place. Liquid level at outlet invert. Tank pumped 2 weeks ago. No solids
present. No gas baffle present on outlet tee.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ iberglass ❑ polyethylene ❑ other(explain):
i
Dimensions:
i
i
Scum thickness
i
Distance from top of scum to t 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
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
•.•�' 34 Wolley Road
Property Address
Peter Ford
Owner owner's Name
information is
required for every Hyannis MA 02601 October 25 2013
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•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
34 Wolley Road
Property Address
Peter Ford
Owner Owner's Name
information is
required for every Hyannis MA 02601 October 25, 2013
page. Cityfrown 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 1.5"
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.):
One inlet, one outlet. Liquid level above outlet invert due to slight backpitch in outlet line for 5'outside
d-box. Not affecting system operation at this time. Line inspected with camera. No solids carryover
present. No high staining over"operating" level.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ No`
Comments(note condition of pump cham r, 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 nspecti Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
34 Wolley Road
Property Address
Peter Ford
Owner Owner's Name
information is required for every Hyannis MA 02601 October 25, 2013
page. Citylfown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4_Infiltrators w/
4 of stone.
❑ 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.):
Camera used to inspect and locate SAS. Damp base with no standing liquid at time of inspection. No
sign of past hydraulic failure. System has 14" of stone under Infiltrator units.
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
(Sins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Wolley Road
Property Address
Peter Ford
Owner Owner's Name
information is required for every Hyannis MA 02601 October 25, 2013
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, sig hydraulic failure, level of ponding, condition of vegetation,
etc.):
15ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17
r - -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
UVSubsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Wolley Road
Property Address
Peter Ford
Owner Owners Name
information is
required for every Hyannis MA 02601 October 25,2013
page. ctiyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
�D= «
y
Lr 57
3 Z Qa _ .�� r
33 � G ,se-
t%%•3M3 TWO 5 MOW bUPOWOn Fomc Sufmaface Satraps disposal System•Pepe 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Wolley Road
Property Address
Peter Ford
Owner Owner's Name
information is
required for every Hyannis MA 02601 October 25, 2013
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: '5
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: 11/03/1999
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:
www.terraserver.com ma.water us s ov
You must describe how you established the high ground water elevation:
Test hole to 10' in 1999 found no ground water. Base of SAS 4.5' below grade. Adjusted ground
water at elv=22.8. Base of SAS at elv=49 per engineered plans. No high groud water in area of
system.
Before fling 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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
34 Wolley Road
Property Address
Peter Ford
Owner Owner's Name
information is
required for every Hyannis MA 02601 October 25, 2013
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
TOWN OF BARNSTABLE
LOCATION 34 i�✓� tL 2 V SEWAGE It
VII_LAGE 41 ASSESSOR'S MAP & LOT : 7� _
INSTALLER'S NAME&PHONE NO. Al S eo '►ew 2 9,
SEPTIC TANK CAPACITY /-!-0
LEACHING FACELITY: (type) I-V /r Z cy:C._ (size) 41 /%X .�
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: —COMPLIANCE DA=E:'L l/ iz^-
Separaticn Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
E .
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
v
may`'
t V Fi
t
I
TOWN OF BARNSTABLE . 2,
LOCATION 3t# i� L[ u SEWAGE #
VILLAGE 4!-Z1-:vd& 3 ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) jv,,C-C_. (size)
NO.OF BEDROOMS Al
BUILDER OR OWNER 1 �
PERMITDATE: 1/ 4j - COMPLIANCE DATE: JL a/ _
i
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
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
0
r
' 1 f l
is
L
i
No. Fee 50 .�
rx -
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pphration for Moogal 6peum Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) �i Eomplete System ❑Individual Components
Location Address or Lot No.3 t, (L)O T Owners 1Nammee,Address and Tel.No.
Assessor's Map/Parcel��0�--(� "'
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq..ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures c,
Design Flow �� gallons per day. Calculated daily flow 7 c-[ gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank GJ� %0 �,.� Type of S.A.S. ' e �� ��
Description of Soil S1fa
Nature of Repairs or Alterations(Answer when applicable) �ST
>>+� JtKsf4 kA C c,r
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environm ntal Code and not to place the system in operation until a Certifi-
cate of Compliance has be y
Signed Date
Application Approved by - Date /t y
Application Disapproved for the following reasons
Permit No. — Date Issued
y 3I Fee S'7� J
17—
THE COMMONWEALTH AF MASSACHUSETTS Entered in comp6ter. Ye
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
21pprication for-Migaaf *patent Construction Permit
Application for a Permit to Construct( ff )Repair( )Upgrade( )Abandon ) �omplete System El Individual Components
Location Address or Lot No.3 (oO t -� Owner's Name,Address and Tel.No.
Assessor's Map/Parcel�70—� 0 "`�•" `�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
J /At
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures c
Design Flow '�� gallons per day. Calculated daily flow Ck 1 gallons.
Plan Date Number of sheets Revision Date
Title i
Size of Septic Tank Type of S.A.S. IACCAAC Ocf' tti'- VV \
Description of Soil S
4'
C+
Nature of Repairs or Alterations(Answer when applicable) AA
C-C4 ` ���s./c(_„C rr. teG►%C c v C4c SfC�P >tti- (T'
Date last inspected:
Agreement: 3
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title`5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has beers-isstr�d"�y" tk� �..-�---
Signed Date
` Application Approved by Date
OF
Application`Disapproved for the following reasons
Permit No. _ Date Issued"
---�—.i ----,----------= -------,----------
+ THE COMMONWEALTH OF MASSACHUSETTS
.BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ` )Repaired( )Upgraded(1/�
Abandoned( )by "D -c .<
`c, has been constructed in accordance
with the provisions of Title 5 and the for EWsposal System Construction Permit No. dated
, ='Installer Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Inspector
rr �r, fit. ; ..
---------------------------------------
No. Fee .
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
'wigpo5ar *p.5tem Construction Permit
' Permission is hereby granted to Construct( )Repair( )Upgrade Abandon(I )
System located at
wC
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit,
Date: �1 9 Approved by G -
1/6i99
a
NOTICE: This Form A To!Be
Be Used For-the Repair Of Failed
Septic Systems Only. .
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERIMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at 3� ��-bI meets all of the
following criteria:
V• The failed stem is connected to a residential dwelling only. There are no commercial r business
ry g o
uses associated with the dwelling.
U .
' e soil is classified as CLASS I and the percolation rate is Iess than or equal to 5 minutes per inch.
• There are no wetlands within 100 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
/There are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the
ma:amum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
• If the S.A.S. will be located with 2�0 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information)
B) G.W. Elevation c7� the MA.X.`High G.W. Adjustmenta
DIFFERENCE BETWEEN A and B
SIGNED : DATE:
[Sketch proposed plan of system on back].
q:health folder.cart
coo
A
7 v'
Commonwealth of Massachusetts
Title 5 Official Inspection Form_
Not for Voluntary Assessments
,M Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
1. Property Information:
34 Wolley Rd.
Property Address
Sheila Whitehouse
Owner's Name
same
Owner's Address
Hyannis MA 02601-2410
City/Town State Zip Code
Date of Inspection: 6/10/08Date
2. Inspector:
Matthew L. Childs
Name of Inspector i 1
same
Company Name
i F
4 Orchid Ln.
Company Address c:) >
W. Yarmouth MA C 02673,
City/Town State d Zip Coded
508-989-1479co
�?
Telephone Number t—
�1 f?7
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 ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6/10/08
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the 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.
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 1 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
,M Subsurface Sewage Disposal System form
A. Certification (cont.)
34 Wolley Rd.
Property Address
Hyannis MA 02601-2410
City/Town State Zip Code
Sheila Whitehouse 6/10/08
Owner's Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
passes
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:
N/A
T
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
i^M
Subsurface Sewage Disposal System Form
A. Certification (cont.)
34 Wolley Rd. '
Property Address
Hyannis MA 02601-2410
City/Town State Zip Code
Sheila Whitehouse 6/10/08
Owner's Name Date of Inspection
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
❑ obstruction is removed
❑ distribution box is leveled or replaced
ND Explain;
N/A
❑ 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: R
N/A
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
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
} S Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
34 Wolley Rd.
Property Address
Hyannis MA 02601-2410
City/Town State Zip Code
Sheila Whitehouse 6/10/08
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (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 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:
N/A
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 4 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
4M
A. Certification (cont.)
34 Wolley Rd.
Property Address
Hyannis MA 02601-2410
City/Town State ZipCode
Sheila Whitehouse 6/10/08
Owner's Name Date of Inspection
D)System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or pohding 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
El 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.]
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.
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 5 of 16
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
34 Wolley Rd.
Property Address
Hyannis MA 02601-2410
City/Town State Zip Code
Sheila Whitehouse 6/10/08 . .
Owner's Name Date of Inspection
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.
r
Y
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
,H y Subsurface Sewage Disposal System Form
B. Checklist
34 Wolley Rd.
Property Address
Hyannis MA _ 02601-2410
Cityrrown State Zip Code
Sheila Whitehouse 6/10/08
Owner's Name Date of Inspection
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
YES NO .
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑' Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
�M
C. System Information
34 Wolley Rd.
Property Address
Hyannis MA 02601-2410
City/Town State Zip Code
Sheila Whitehouse 6/10/08
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 gpd.
1
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 years usage (gpd)): N/A
Sump pump? ❑ Yes ® No
current
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment: N/A
N/A
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): N/A
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: N/A
N/A
Last date of occupancy/use: Date '
Other(describe): N/A
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
34 Wolley Rd.
Property Address
Hyannis MA 02601-2410
City/Town State Zip Code
Sheila Whitehouse 6/10/08
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: owner
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: N/Agallons
How was quantity pumped determined? N/A
Reason for pumping: N/A
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:
Installed 11/4/99 per disposal works construction permit on file at Barnstable BOH.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 9 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
34 Wolley Rd.
Property Address
Hyannis MA 02601-2410
Cityrrown State Zip Code
Sheila Whitehouse 6/10/08
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
4'
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.):
All in good working order at time of inspection..
Septic Tank (locate on site plan):
Depth below grade: 1.5'
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No
certificate)
Dimensions: 9'x5'x6'outside 1500 gal.
.2'
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 3.7
. 1,
Scum thickness
.4,
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
.9'
How were dimensions determined? sludge judge
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 10 of 16
- TOWN OF BARNSTABLE
LOCATION V&n, Q SEWAGE#3..
VILLAGE �4 ASSESSOR'S MAP&PARCEL 7 0
H'�'S NAME&PHONE
3.� .a?=a ma's
SEPTIC TANK CAPACITY A
LEACHING FACILITY: (size) X S L
NO.OF BEDROOMS
OWNER S7,)�� 1-
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S Feet
Private Water Supply Well and Leaching Facility(If any wells exist on'
site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist within
300 feet of leaching facility) Feet
FURNISHED BY
rVr,1 O
Qj
- 1P`
930
c3dfN
o
47
91
v /
Q
(d
f
Commonwealth of Massachusetts "
Title 5 Official Inspection Form
Not for Voluntary Assessments
,M Subsurface Sewage Disposal System Form
C. System Information (cont.)
34 Wolley Rd.
Property Address
Hyannis MA 02601-2410
City/Town State Zip Code
Sheila Whitehouse 6/10/08
Owner's Name Date of Inspection
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 shows no signs of leakage and appears to have been maintained regularly at time of inspection.
Grease Trap (locate on site plan):
Depth below grade: N/Afeet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
Dimensions: y
N/A
Scum thickness N/A
Distance from top of scum to top of outlet tee or baffle N/A
Distance from bottom of scum to bottom of outlet tee or baffle N/A
Date of last pumping: N/A
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.):
N/A
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
N/A
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
,M s Subsurface Sewage Disposal System Form
C. System Information (cont.)
34 Wolley Rd. '
Property Address
Hyannis MA 02601-2410
City/Town State Zip Code
Sheila Whitehouse 6/10/08
Owner's Name Date of Inspection
Tight or Holding Tank(cont.)
Dimensions: .
N/A
Capacity: N/A
gallons
Design Flow: N/A
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: N/A . Alarm in working order: ❑ Yes❑ No
Date of last pumping: N/A
Date
Comments (condition of alarm and float switches, etc.):
N/A
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0.0,
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 has no solids carryover or leakage at time of inspection.
Pump Chamber(locate on site plan):
Pumps in working order: ElYes ❑ No
Alarms in working order: ❑ Yes ❑ No
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
34 Wolley Rd.
Property Address
Hyannis MA 02601-2410
City/Town State Zip Code
Sheila Whitehouse 6/10/08
Owner's Name Date of Inspection
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
N/A
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number-.
® leaching chambers number: 4
❑ 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
4vegetation, etc.):
4 Infiltrators were dry at time of inspection'showing no signs of hydraulic failure.
I
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System p 9 Y
Page 13 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
5.1 Subsurface Sewage Disposal System Form
G'M
C. System Information (cont.)
34 Wolley Rd.
Property Address .
Hyannis MA 02601-2410
City/Town State Zip Code
Sheila Whitehouse 6/10/08 .
Owner's Name Date of Inspection
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
N/A
Depth—top of liquid to inlet invert N/A
Depth of solids layer N/A
Depth of scum layer ' N/A'
Dimensions of cesspool N/A
Materials of construction N/A
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Privy (locate on site plan):
Materials of construction: N/A
Dimensions N/A
Depth of solids N/A
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
N/A
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 14 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
,M Subsurface Sewage Disposal System Form
C. System Information (cont.)
34 Wolley Rd.
Property Address
Hyannis MA 02601-2410
City/Town State Zip Code
Sheila Whitehouse 6/10/08
.Owner's Name Date of Inspection
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.
® cC—V Re
/S
A 1-21114
A 343' 42T
t
LWhitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
4M
C. System Information (cont.)
34 Wolley Rd.
Property Address
Hyannis MA 02601-2410
City/Town State Zip Code
Sheila Whitehouse 6/10/08
Owner's Name Date of Inspection
Site Exam:
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water:
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. 11/4/99
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:
Checked test hole data from system design plans. System was installed within reasonable limits and
has adequate groundwater seperation.
Whitehouse.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 16 of 16
Regulatory Services
&kRNSTABLE. : Thomas F. Geiler, Director
Mnss.
059. ,�� Public Health Division
�'�rFn Ma's a
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304 }
REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number of
bedrooms approved at a particular property would be listed on the "Disposal Works
Construction Permit"..
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIMisclaimer Private Septic Inspections.DOC