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c� Commonwealth of Massachusetts
Title 5 Official Inspection Form .
I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402&404 Bearses Way Lk
Property Address
Ronald Bourgeois C,
Owner Owner's Name s.
information is Hyannis Ma 02601 10-21-19 LL
required for every y
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. Inspector Information
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
key. ,
Co Route
130
w Company Address
Sandwich Ma 02563
City/Town State Zip Code
,xkv (508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑ Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Brett Hickey �: �.�.•.•�. .��...� .. 10-21-19
'pmu:1019.1O.Y[1]'ST.]]-0.VO
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 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.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
�= Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402&404 Bearses Way
v
Property Address
Ronald Bourgeois
Owner Owner's Name
information is Hyannis Ma 02601 10-21-19
required for every y
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:
The system was in working order at the time of inspection. '
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
i
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402&404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is Hyannis Ma 02601 10-21-19
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ 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.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
�e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402&404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is Hyannis Ma 02601 10-21-19
required for every y
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
❑ 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ a 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.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
i
c� ssachusetts
Commonwealth of Ma
�e Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402&404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is Hyannis Ma 02601 10-21-19
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ O Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ 0 Liquid depth in cesspool is less than 6"below invert or available volume is less
than 1/2 day flow
❑ Q Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ El Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ a Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ 0 Any portion of a cesspool or privy is within a Zone 1 of a public water supply
well.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ El 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.]
❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ 0 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
I , -
I `
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402&404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owners Name
information is Hyannis Ma 02601 10-21-19
required for every y
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
El ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ 0 Were any of the system components pumped out in the previous two weeks?
El ❑ 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?
O ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
❑ El Was,the facility or dwelling inspected for signs of sewage back up?
❑ ❑ Was the site inspected for signs of break out?
El ❑ Were all system components, excluding the SAS, located on site?
0 ❑ 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?
❑ 0 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.
❑ El 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.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402&404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is Hyannis Ma 02601 10-21-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
4 Number of bedrooms(design): Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 441/GPD
Description:
6
Number of current residents:
Does residence have a garbage grinder? ❑ Yes Q No
Does residence have a water treatment unit? ❑ Yes E] No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes EI No
information in this report.)
Laundry system inspected? ❑ Yes EI No
Seasonal use? ❑ Yes [E No
See below
Water meter readings, if available(last 2 years usage(gpd)):
Detail
2017- 103,972gallons 2018- 136,380gallons
Sump pump? ❑ Yes ❑■ No
current
Last date of occupancy: Date
t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402&404 Bearses Way
v
Property Address
Ronald Bourgeois
Owner Owner's Name
information is Hyannis Ma 02601 10-21-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
NA
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:
I •
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: Owner- last pumped 2018
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
i
i
15insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
gal Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402&404 Bearses Way
L
Property Address
Ronald Bourgeois
Owner Owner's Name
information is Hyannis Ma 02601 10-21-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
E 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:
2005 per plans
Were sewage odors detected when arriving at the site? ❑ Yes X No
5. Building Sewer(locate on site plan):
3'
Depth below grade: feet
Material of construction:
❑ cast iron ❑■ 40 PVC ❑ other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
1. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v
402&404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name .
information is required for every -Hyannis annis Ma 02601 10-21-19
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
2'
Depth below grade: feet
Material of construction:
❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
1
Dimensions: 500gallons
611
Sludge depth:
30It
Distance from top of sludge to bottom of outlet tee or baffle
411
Scum thickness
611
Distance from top of scum to top of outlet tee or baffle
1311
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' <P Subsurface.Sewage Disposal System Form -Not for Voluntary Assessments
402&404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owners Name
information is Hyannis Ma 02601 10-21-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
NA
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):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑,polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
t5insp.doc•rev.7262018 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
402&404 Bearses Way
v�
Property Address
Ronald Bourgeois
Owner Owners Name
information is Hyannis Ma 02601 10-21-19
required for every y
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):
0"
Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The d-box was in working order at the time of inspection.
I
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402&404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is Hyannis Ma 02601 10-21-19
required for every y
page. City/Town 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.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan,.excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
(3)500 gallon chambers
El leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
402&404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is Hyannis Ma 02601 10-21-19
required for every y
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.):
The SAS was in working order at the time of inspection. Chambers were 1/2 full when viewed.
I
I
i
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
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.7262018 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 14 of 18
i
c Commonwealth of Massachusetts
1= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402&404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is Hyannis Ma 02601 10-21-19
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy (locate on site plan):
NA
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
A
l5insp.doc•rev.7262018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts;:
�T'itle 5""Official' Inspection, Form
�� Subsurface-Sewage Disposal System Form Not for Voluntary Assessments
402&404 Bearses Way
Property Address,
RonaldBourgeois.' r..
Owner Owner's Name
information is H annis` Ma, 02601 10-21-19
required for every, Y
page: City/Town .State ' Zip Code Date of Inspection
D: System Information (cont.
14. Sketch.Of$ewage Disposal System'
Provide a view of the sewage disposal system, including ties to at least two"permanent reference
landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters
the,building'`Check one of the boxes below:
�■; hand-sketch in the area below
drawing attached separately
n
I k , •
f
• ifi �` '-'3.+t'y „w,, tic» .
t5insp.doc rev 7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
1 ,•
c� Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402&404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is Hyannis Ma 02601 10-21-19
required for every y
page. City/Town 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: No GW @ 144'
feet
Please indicate all methods used to determine the high ground water elevation:
0 Obtained from system design plans on record
4-1-2005
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:
A plan on file at the local Board of Health was used to determine high groundwater.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 402&404 Bearses Way
Property Address
Ronald Bourgeois '
Owner Owner's Name
information is Hyannis Ma 02601 10-21-19
required for every y
page. City/Town, State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
A. Inspector Information: Complete all fields in this section.
�■ B. Certification: Signed& Dated and 1, 2, 3, or 4 checked
�■ C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria)and 6(Checklist)completed
■❑ D. 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
I
l5insp.doc-rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
Commonwealth of Massachusetts
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is Hyannis MA 02601 0923/13
required for every
page. Citylrown State Zip Code Date of Inspection
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector:
key to move your I /
cursor-do not Michael Kellett I�Yn
use the return Name of Inspector
key.
Aardvark Environmental Inspections
Company Name
PO Box 896
Company Address
East Dennis MA 02641
City/Town State Zip Code
508-385-7608 SI 3742
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
.� 0923/13
Ins ecdor's Signature Date
i
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.
t5lns•11/10 Title 5Of icial InspectiLffftce Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
o 402-404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is required for every Hyannis MA 02601 0923/13
page. City/Town state Zip Code Date of Inspection
& Certification (cont.)
Inspection Summary:Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure crtteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ one or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system,upon completion of the replacement or repair,as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y,N, ND)for the following statements.If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health_
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t51ns•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
N Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
"( 402-404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is required for every Hyannis MA 02601 09/23/13
page. City/Town state Zip Code Date of Inspection
B. Certification (cunt.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a yeardue 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 mannerwhich 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
Mns•WiD TMe 5Offelat Inspedfon Form:Subsurtace Sewage Dispoeat System•Page 3 of V
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is Hyannis MA 02601 0923/13
required for every, y
page. Cityrrown 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
❑ ® 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 Y2 day flow
t5ins•11/10 T@le 5Official Inspection Form:Subsurface Sewage Deposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-404 Bearses Way
1, Property Address
Ronald Bourgeois
Owner Owner's Name
information is required for every Hyannis MA 02601 09f23/13
page. Cityfrown State Zip Code hate 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 N the well water analysis,performed at a DEP certified
laboratory,for fecal colifomn 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 faits.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,•therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either`yes"or"no"to each of the following,in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone 11 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-11/10 Me 5 official inspection Form:Subsurface Sawage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is required for every Hyannis MA 02601 0923/13
page. Cityfrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"Yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner,occupant,or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?.
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,excluding the SAS,located on site?
® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank
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): 4 Number of bedrooms(actual): 4
DESIGN flow based on 310 CMR 15203(for example: 110 gpd x#of bedrooms): 440
! t5ins•11110 Tele 5Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is required for every Hyannis MA 02601 0923/13
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
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)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Current
Date
Commerciailindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.fL,etc):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitarywaste discharged to the Title 5 system? ❑ Yes ❑ No
9 Y
Water meter readings,if available:
t5ins•11/10 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
402-404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is required for every Hyannis _ MA 02601 0923/13
page. Cityfrown state Zip Code Date of Inspection
D. System Information (cunt.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes,attach previous inspection records,if any)
I
❑ Innovative/Altemative 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 VA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5lns-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is required for every Hyannis MA 02601 0923/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components,date installed(if known)and source of information:
04/14/05 per BOH
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2.8
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.):
Septic Tank(locate on site plan):
Depth below grade: 2.2feet
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: 1,500 gal
.Sludge depth:
2"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
u
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-404 Bearses Way
lg —
Property Address
Ronald Bourgeois
Owner Owner's Name
information is
required for every Hyannis MA 02601 0923/13
page. Cityfrown 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
28"
Scum thickness
3"
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? measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
The tank was sound and tight with tees in place and liquid at outlet invert
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is required for every Hyannis MA 02601 0923/13
page. City/rown State Zip Code Date of Inspection
D. System Information (cunt.)
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•11/10 Title 5 Official Inspection Form:Subsurrace Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is required for every Hyannis MA 02601 0923/13
page. Cityrrown state Zip Code Date of Inspection
D. System Information (font.)
Distribution Box(f present must be opened)(locate on site plan):
Depth of liquid level above outlet invert even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box,etc.):
The box was level and tight with no sign of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Soil Absorption System(SAS) pocate on site plan,excavation not required):
If SAS not located,explain why:
t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-4M Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is required for every Hyannis MA 02601 0923/13
page. Cityfrown state Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ leaching galleries number.
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/aftemative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation,etc.):
This system has three five hundred gallon drywelis surrounded by 4'of stone.There was 3"of liquid
in the chambers.
Cesspools(cesspool must be pumped as part of inspection)Qocate 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•11/10 Title 5 Official Insped ion Forth:Subsurface Sawage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is required for every Hyannis MA 02601 0923/13
page. Cityrrown 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•11/10 Title 5 Official Inspection Form:Subsurrace Sewage Disposal System•Page 14 of 17
i
I .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is required for every Hyannis MA 02601 0923/13
page. City/Town state Zip Code Date of Inspection
D. System Information (cunt.)
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
it
rear
16
31
20
38 71
56
I
I
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
`t 402-404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is required for every Hyannis MA 02601 0923/13
page. Citylrown state Zip Code Date of Inspection
D. System Information (cunt.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
20.0
Estimated depth to high ground water feet
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within.150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators,installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS maps show an elevation of over 20.0 feet.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins•11/10 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
402-404 Bearses Way
Property Address
Ronald Bourgeois
Owner Owner's Name
information is required for every Hyannis MA 02601 0923/13
page. Cityfrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Lippman
Owner Owner's Name
information is Hyannis ma 02601 3/7111
required for every Y
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. General Information
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Chad Hathaway
use the return Name of Inspector
key.
H.P.S.
Company Name
1 Warwick way
Company Address
Mashpee Ma. 02649
City/Town State Zip Code
1 774 274 2581 12866
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 16.340 of
Title 5(310 CMR 15.000).The system:
CD
® Passes
❑ Conditionally Passes ❑ Fail s
❑ Needs Further Evaluation by the Local Approving Authority
3/7111 U
Inspecto Signature Date --
c�
The system inspector sh submit a copy of this inspection report to the Approving Authority(Bo'a1d
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.
I
l I
t5ms•09108 Title 5 Official Inspection Form:Subsurface Sewage Di i j I System•Page II
of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Lippman
Owner Owner's Name
information is required for every Hyannis ma 02601 3/7/11
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E[always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
tank at working level with inlet+outlet tees DBox level with equal flow leach chamber are dry with no
signs 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
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Paige 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Lippman
Owner Owner's Name
information is required for every Hyannis ma 02601 3/7/11
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
tins.09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402404 Bearses Way
Property Address
Lippman
Owner Owner's Name
information is required for every Hyannis ma 02601 3/7/11
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well"*.
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
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
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or dogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins-09108 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Lippman
Owner Owner's Name
information is required for every Hyannis ma 02601 3/7/11
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09108 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
r 402-404 Bearses Way
Property Address
Lippman
Owner Owner's Name
information is Y
required for every Hyannis ma 02601 3/7/11
page. C4rrown 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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402404 Bearses Way
Property Address
Lippman
Owner Owner's Name
information is required for every Hyannis ma 02601 3/7/11
page. CitytTown 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? [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)):
Detail:
o
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•091M rite 5 Official Inspection Forth:subsurface sewage Disposal system-Page 7 or 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402404 Bearses Way
Property Address
Lippman
Owner Owner's Name
information is required for every Hyannis ma 02601 3/7/11
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:
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):
l5ins•OW08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Lippman
Owner Owner's Name
information is required for every Hyannis ma 02601 36111
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:
2005 plan
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20"feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 15'
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 21
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"L 5'8"W 4'4"Deep
Sludge depth:
4"
t5ins.09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402404 Bearses Way
Property Address
Lippman
Owner Owner's Name
information is required for every Hyannis ma 02601 3/7/11
y
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
32"
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
14"
How were dimensions determined? sludge judge+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.):
pump tank 1 year after move in date then pump every 2 years after that.
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
I
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official . Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402404 Bearses Way
Property Address
Lippman
Owner Owner's Name
information is required for every Hyannis ma 02601 3/7/11
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Lippman
Owner Owner's Name
information is required for every Hyannis ma 02601 3/7/11
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert water is at bottom of outlet pipe
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 level and distribution to outles equal
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes. ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System(SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
dug up leaching chamber no signs of failure no water inside chamber at time of inspection.
t5i5ins.pg/pg Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
IVTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402404 Bearses Way
Property Address
Lippman
Owner Owner's Name
information is required for every Hyannis ma 02601 3/7/11
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3
❑ 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.):
F
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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Lippman
Owner Owner's Name
information is required for every Hyannis ma 02601 3/7/11
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.):
L
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.):
t5hr.•pg/pg Title 5 Official Inspection Forth:Subsurtace Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Lippman
Owner Owners Name
information required for e is very Hyannis ma 02601 3/7111
page. Cityrrown 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
HoU
fib 13
v U Q 3 .
l -�--J
►� 13 t' Ta.,k '<n I.Q4
� 1 3i '
(01
13 Q` 1 (o
93 .aD'
t5ins,0901 Title 5 official Inspection form:Subsurface Sewage Disposal System•Page 15 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
.�" 402404 Bearses Way
Property Address
Lippman
Owner owner's Name
information is H annis ma 02601 3/7/11
required for every y
page. Citylrown 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: no g/w @ 144"
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
2005
If checked, date of design plan reviewed: Date
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:
test log for septic up grade showed no G/W at 144" leach chamber is 3' below grade +2' of chamber
bottom of leaching 5'deep min seperation from septic to G/W is 7'
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09108 Me 5 official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
I ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
402-404 Bearses Way
Property Address
Lippman
Owner owner's Name
information is required for every Hyannis ma 02601 3f7111
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
15ins-09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 17 of 17
I
Citizen Web Request Page 1 of 2
:_..... Citizen Request Management - Internal Use
Request ID: 23968 Created: 12/22/2008 08:43:59
Status: Assigned To Staff Assigned To: Cabot, Jaime
Health Office
Anonymous: No Category: Chapter II : Housing
Substandard
E.C. Date: 01/08/2009
j Created By: Wadlington, Ellen Citations:
Health Office
Time Worked: 3.00 Response Time: 6.50
1
-� Requestor Details:
Email:
Request Location:
402 BEARSE'S WAY
Hyannis, Ma 02601
Parcel Number: Map: 292 Block: 160 Lot: 000
Request:
Septic issues, backing up in house. Landlord has been advised of problem but has done
nothing.
Request Work History:
Entered on 12/23/2008 09:20:50
by Cabot, Jaime
JAC inspected property at 3:15pm on 12/22/2008. Was met by Junior Caraballe at the house
his wife and 3 children were in the house. JAC donned an H95 Respirator and entered the dwellin
where plastic sheeting had been placed on the carpet in the hall between the bath room and the
bedrooms, there was less than a half inch of water on the carpet. The toilet contained fecal matt(
and was blocked. The Bath tub contained wet clothes and was half full of liquid, piles of clothes
and mattresses were observed in the bedroom. JAC photographed the scene and spoke to the
occupants advising them of the Health risks present. JAC called Terri Lippman inquiring when a
septic pumper was going to arrive. Terri Lippman stated that ACE Septic had been contacted and
was to have been there that day. I informed her that they had not been there and that she shoul
make additional efforts to have the septic tank pumped and any blockages corrected. JAC spoke
http://issgl2/IntemalWRS/WRequestPrint.aspx?ID=23968 12/23/2008
'itizen Web Request Page 2 of 2
i
to Terri Lippman later that day and advised her that an order letter was being issued and
explained the contents of the order letter and what was needed to correct the violations.
-Internal Note History:
System entry on 12/22/2008 08:43:59:
Assigned to Cabot, Jaime
Entered on 12/23/2008 09:20:50
by Cabot, Jaime
http://issgl2/IntemalWRS/WRequestPrint.aspx?ID=23968 12/23/2008
TOWN OF BARNSTABLE
I:�"'LAi70N ��f _ SEWAGE
VILLAGE— ASSESSOR'S MAPP&SLOT
INSTALLER'S NAME&PHONE NO. -
SEPTIC TANK CAPACITY --
LEACHING FACILITY: (type) o '_ (size)
NO. OF BEDROOMS Dcr
BUILDER OR OWNS
PERMITDATE: COMPL CE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
-,-on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
,within 300 feetOleping fac* J Feet
Furnished by
r•
its
I_Z o
TOWN OF BARNSTABLE
SEWAGE #
'✓L.;�P.GE /�7t/�-�/'�/,�' ASSESSOR'S MAP & LOTa f5�
vS T 15
ALLER'S NAN E&PHONE NO.
SEP T:C TANK CAPACITY
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUII.DER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
l
AA aye
Ag s� y
Ac
c 2u
e
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property AlOX- S-e� U.,y
Owner's name /�, 0',1 LA-0,—
Date of Inspection
PART A
CHECKLIST
Check if the following have been done:
f/ Pumping information was requested of the owner, occupant, and Board of
Health.
None of the system components have been pumped for at least two weeks
and the system has been receiving normal flow rates during that
period. Large volumes of water have not been introduced into the
system recently or as part of this inspection.
As built plans have been obtained and examined. Note if they are not
available with N/A.
_Z The facility or dwelling was inspected for signs of sewage- back-up.
The site was inspected for signs of breakout. .
ZAll system components, excluding the SAS, have-' been located on the
site.
The septic tank manholes were uncovered, opened, and the interior of
the septic tank was inspected for condition of baffles or tees,
material of construction, dimensions, depth of liquid, -depth of
sludge, depth of scum.
The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
_ZThe facility .owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
S EP )1995
8
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
_ number of bedrooms
- number of current residents
,. garbage grinder, yes or no
_Y laundry connected to system., yes or no
(/ seasonal use; yes or no
If nonresidential, calculated flow:
-4H 1q,001
Water meter readings, if available: I l o a-et° C�h"
Last date of occupancy
GENERAL INFORMATION
Pumping records and source of inform do
e
6. /Y
System pumped as part of inspection, yes or no
if yes., volume pumped y L S a d
Reason for pumping:
�-S �G ✓Z 92 O -o' 4,Cj,4 1 L A 3411-C4 e o M Gl, C-;o i )
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)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information: C
t J
Sewage odors detected when arriving at the site, yes or no
f
9
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK:
(locate on site play )
depth below grade:
material of cons uction: concrete metal FRP other(explain)
dimensions: '
sludge depth
distance from top of sludge to bottom' of outlet tee or baffle
scum thickness
distance from top of scum to top of outlet tee or baffle
distance from bottom of scum to bottom of outlet .tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage recommendations for repairs, etc. )
DISTRIBUT/land
(locate o
liquid level above outlet invert
Comments:
(note if stribution is equal, evidence of solids carryover,
evidence nto or out of box, recommendation for repairs, etc. )
PUMP CHAMBER:
(locate on/ons
an)
puorking order, yes or no
Comments:
(note cond pump chamber, condition of pumps and appurtenances,
recommendsr maintenance or repairs,etc. )
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) :_
(locate on site plan, if possible; excavation not required, but may be
approximated by non-intrusive methods)
If not determined to be present, explain: ..
Type /�
leaching pits and number l 1 0 �� ,�I o .n,, Pub c)e
leaching chambers and number
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions S�
overflow cesspool, number o ar "
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of veget t 'on, recommendations for maintenance or repairs,etc. )
CESSPOOLS (locate on site plan) :
number and configurationJre
depth-top of liquid to inlet invert
depth of solids layer 1G ' '
depth of scum layer %
dimensions of cesspool - ' 8' '
materials of construction
indication of groundwater
inflow (cesspool must be pumped as
part of inspection) d &J A i m rz
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs,etc. )
e D
PRIVY:
(locate on site plan)
materials of construction
dimensions
depth of solids
Comments:
(note condition of soil, .signs of hydr lic .failure, level of ponding,
condition of vegetation, recommendati s for maintenance or repairs,etc. )
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B - -
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
n A��
DEPTH TO GROUNDWATER
) S 4 depth to groundwater
method of. determination Qr app oximation:
�D,l-�
12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
Backup of sewage into facility?
j✓ Discharge or ponding of effluent to the surface of the ground or
surface waters?
_�✓ Static liquid level in the. distribution box above outlet invert?
Liquid depth in cesspool <6" below invert or available volume< 1/.2 day
flow?
A✓ Required pumping 4 times or more in the last year?
number of times pumped
Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
below the high groundwater elevation?
within 50 feet of a surface water?
_ // within 100 feet of a surface water supply or tributary to a surface
water supply?
within a Zone I of a public well?
A/ within 50 feet of a bordering vegetated wetland. or salt marsh
(cesspools and privies only, not the SAS.) ?
within 50 feet of a private water supply well?
4Z less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis? If the well
has been analyzed to be acceptable, attach copy of well water analysi.
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
a ._
TOWN OF /'/�,S/7 -2 BOARD OF HEALTH
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D - CERTIFICATION
-TYPE OR PRINT CLEARLY-
PROPERTY INSPECTED
STREET ADDRESS y4,2 �' .fin a r<Se. OL S
ASSESSORS MAP, BLOCK AND PARCEL #
OWNER' s NAME
PART D - CERTIFICATION
NAME OF INSPECTOR W.E. Robinson Sr
COMPANY NAME W.E. Robisnon Septic Service
COMPANY ADDRESS P.O. Box 1089 Centerville MA 02632
Street Town or City State ZIP
COMPANY TELEPHONE ( 508 ) 775-8776 FAX
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system a
this address and that the information reported is true , accurate , and
complete as of the time of inspection . The inspection was performed and any
recommendations regarding upgrade , maintenance , and repair are consistent
with my training and experience in the proper function and maintenance of on
site sewage disposal systems .
Check one:
System PASSED
The inspection which I have conducted has not found any information
which indicates that the system fails to adequately protect public
health or the environment as defined in 310 CMR 15 . 303 . Any failure
criteria not evaluated are as stated in the FAILURE CRITERIA section of
this form.
System FAILED*
The inspection which I have conducted has found that the system fails t
protect the public health and the environment in accordance with Title
5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE
CRITERIA of this inspection form.
4
Inspector Signature Z'..) Date
One copy of this certification must be provided to the OWNER, the BUYER
( where applicable) and the BOARD OF HEALTH.
* If the inspection FAILED, the owner or operator shall upgrade the system
within one year of the date of the inspection, unless allowed or required
otherwise as provided in 310 CMR 15 . 305 .
partddoc
Department Of Public Health/ Department of Labor & Industries
NOTIFICATION OF DELEADING WORK
All sections of this form must be completed in order to comply with
the notification requirments of M.C.L.C. 111 5197
FILE NUMBER
Contractor performing project Atlantic Home Deleading. . License mo # 001025
Address of'Project
Building Name (if any) Floor
Street Address 394-396 Bearsesway Apt. No.
City Hyannis Zip 02601
Deleading Method: DRY SCRAPING HEAT GUN ENCAPSULATION DEMOLITION
(circle all that apply)
POWER SANDING CAUSTICS REPLACEMENT OTHER
If "Other" selected,: please explain
Check one: dwelling- is Multi-family X single family,
Start date June 23, 1993 Completion Date June 29, 1993
.X X
When will work be done: am pm weekends?.
Project Supervisor Name Raymond Benson License No # 001025 .
Property Owner Sandwich Co;Operative Bank
Address 100 Old King's Highway --
City Sandwich State MA Zip 02563
Telephone
(508) 888-0026
Atlantic Home Deleading & Construction/Ray Benson
In case of emergency contact:
Phone* : '
day "(508)1- 830-9383, evening same
In accordance with Chapter 773 of the Acts of 1987, Massachusetts General Laws
C. 111 5197, 454 CMR 22.00 and 105 CMR 460.000, notice of the date and method (s)
of removal or covering of paint, plaster soil or other accessible material contaihi ng
dangerous levels of lead, is to be provided to the following persons prior: to the
beginning of deleading.
1. Occupants of the dwelling unit
2. All other occupants of the residential premises, if any
3. Director, Childhood Lead Poisioning Prevention Program
Department of Public Health, 305 South Street, Jamaica Plain, MA 02130
4. Lead Removal Program, Bureau of Technical .Services
Department of Labor and Industries, Division of Industrial(Safety
100 Cambridge Street, Room 1101, Boston, MA :02202
5: Local Board of Health/Code Enforcement: Agency
6: Massachusetts Historical Commission
(if premises is listed on the State Register of Historic Places)
The undersigned hereby states, under the penalties of perjury, that he/she 'has read
and understood the Commonwealth of Massachusetts Deleading Regulations, 454 CMR
22.00, and Lead Poisioning Prevention and Control Regulations, 105 CMR 460.00, and
that the information contained in this bgtification is true and correct to the best
of his/her knowledge and belief.
6/18/93 Signed
Date
Title: President
Company: Atlantic Home .Deleading & Construction
Office Use Only
' y
Inspector Name Date of Inspection
` L�:C,A,IP,ION . S E WA/G E PERMIT N0.
VILLAGE
INSTALLER'S NAME & ADDRESS
rT
B U I'L D OR OWNER
feee �{d�
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
X
6'
tA
_ w A
VQ,w
s'AA
J
r THE COMMONWEALTH OF MASSACHUSETTS
't BOARD OF HEALTH
e4'o .sr*lle C G
............/I.GLI't-.......OF.....................................................................................
Tntif irt6 of Tompliattrit
THIS 1,S TO CERTIFY, T at the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by..............ZK k./............ =---.--®vA-----------------------------------------
,.....
Installer
01
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit iVo......r .9-1...................... dated......--.�..'.s".-..�1................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
b S ........................................... Inspector.....--_- � —
DATE...........................8_.�. (v/ -•-----------••----..._.........----• ----•---•---•--•--........--
L--
No...('%.f2_....._ Fim.®..`................
THE COMMONWEALTH.OF MASSACHUSETTS
BOARD I-I EALT�
�:-�. .. .................OF...........................................c��-d------C�-.---- ........... .........
Appliration for Uispvii al Marks Tonstrnr#iun Vamit
Application is,.,hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System
.._......Loc .. t ---
W ........................................ ...:1l*. ....,.... ....•..... . . ... .... . ......:.. ..................r- . .... ---
Installer Address
Type of Building Size Lot............................Sq. feet
aDwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures ..... ------------------------------------------------------------
W Design Flow............................................gallons per person per day. Total daily flow-._.--_-- .-.................. ...............gallons.
WSeptic Tank—Liquid capacity......_...•.gallons Length................ Width................ Diameter________-____- ............gallons.
x Disposal Trench—No. .................... Width...._l,/.......... Total Length....__.._ ._ Total leaching area....................sq. ft.
Seepage Pit No........... .. �✓
�•- pag .__.. Diameter.._.{............. Depth below inlet._._. ........... Total leaching area..................sq. ft.
Z Other Distribution bo ( ) Dosing tank ( )
Percolation Test Results Performed by-------------------------------------------------------------------------- Date.........................................
a
,.� Test Pit No. 1................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........................
-I-, •......--•--•-------•--.--'�•-•••-...-•••--•-• .......... .......... .•-• -•--•-• - -- -••-•-•--•---...-----
o ,_ .�._ J
x Descripti9rl�ofe �> -••-
UN re of Re )Airs or Alterati ns—Q wer whin plicable.- � -- . -•--- `•-
Agreement.
The undersigned agrees to install the aforede ribed Individual Sew e Disposal System in accordance with
the provisions of TITLi, ' 5 of the State Sanitary de-The undersigne ur er agrees not to place the system in
operation until a Certificate of Compliance has,be i ued by th oard th.
gned....
Date
Application Approved By............ ................... :1�................... ........................••.
- Date
Application Disapproved for the fo win ons-.............................................................................................................. i
f
j Date
Permit No......vT y Issued -' - r
.......................................
Date
No..1 2-...... Fps.�.'.__C) o.._
THE COMMONWEALTH OF MASSACHUSETTS
�"'� BOAR® !-I E LT
......../......:� �.--.....OF........ ..................................................................
Appliration for Uiipoottl Works Tongtrurtion Frrutit
4
Application is ereby made for a Permit to Construct ( ) or Repair (X) an Individual Sewage Disposal
System at:
+ L�ZI.I.-tip.,•'
........... .. ..... •••--•-•-•- ........................... r� .... •----•---...........• -----••-•
-- - ---
W .....................o11 r •—
................`�_.....-----------•-------�-�-/-/-------------------.-.-�.- c* ..... ____ i'��%
---3-...---- •................
Installer Address
Type of Building Size Lot............................Sq. feet
�. Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons____________________________ Showers — Cafeteria
a' Other fixtures __________________________________
W Design Flow..................2........................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity.___.._.____gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No..................... Width.j,,7V.......... Total Length..... �__ Total leaching area....................sq. ft.
> Seepage Pit No__________ ______ Diameter..../__.......... Depth below inlet__ ........... Total leaching area............._....sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water.........................
rX4 Test Pit No. 2.........._... imutes per inch Depth of Test Pit.................... Depth to ground water........................
x Descri ti of� = V.
...................................... --- .- ............................... ---- -------------- ............................................................
x --------=----------------------------------•---- v -- ---- --- =
jU Nature o Re irs or terati ns—A wer when ---- -- _
--- -------------•-- --2.. --•--- ...._.
Agree...
The undersigned agrees to install the aforede ribed Individual Sew e Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary e—The undersigne ur er agrees not to place the system in
operation until a Certificate of Compliance has be is ed by th oard q th.
igned....---------•------- -------- --- ....... -------•••------•---.....----_---- ....
Date
ApplicationApproved By................................ ..........................................................------•-•-----••--•..................•------• ........................................
Application Disapproved for the f o win a ons_________________________
•--•---^-•-----•.............•-------...--.--------•---------__.___Date---____....---
......................•---------------•--------------------•---------------------------•--------•-----------------------------------------------••------------
Permit No......n y_� __ Issued_______�__S + •
- ----- ^• ate
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
114.41,j rAll!L
�l�lc..:. OF........................................
:............ ... ............ ...... .............................................
Trrtifiratr of Tontplinnre
THIS IS TO CERTIFY, T at the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by..........-•--_�he—`i-!'_-` 06< .
..............................................•-..-----------._........---........---.._......----------.._.._................---------.._............._
�j Installer
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.:__':; _��_ ______________________ dated.......... __'_. �.'..T ...............
i
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. "e /
6-s� 8 7e-
DATE. ............................... Inspector ---------•-__--••--
THE COMMONWEALTH OF MASSACHUSETTS r
BOARD `Of AEALTH
F1 tr
...uLc.O� ....OF....:....'� ��(/rs/•��f�L O!/
No...... ................ �FEE.............?ryC.
orko Tonotrttrtionrrntit
Permission is hereby granted__.._ _____________ _��a �r l____._. v -
-•-------•--------------------•--.....-------........-----..............._----•••-
to Construct ( ) or'Repair ()() an Individual Sewage Disposal System
atNo..---....... (E .....n........ ..........................--......................................................................................
Street
as shown on the application for Disposal Works Construction Permit No.__a__��__7...... Dated........ ............
n
• / Bdard of Health
DATE - �--"-- ----_...._• :•:w :::.... "'+,�.
FORM 1255 HOBBS & WA0REN,,1NC.. PUBLISHERS
_ R SAS
l' M EX ST. GRADE OVER MAXIMUM COVER PER BO -4 OWN RO 1 R H TO BE CIUT 1
_
ALL OUTLET PIPES fttou THE
A A
DIST
RIBUTION F BOX SHALL BE
I ,
I ON tr ,.,.,
VENT PIPE O Leost 24 Inches# II SECTI COVER
s a ) _ . ,. '- CONCRETE ,: ..,...,...., ,
NOTE. L PIP LEAST 2 rr. «.
AL ES-ARE TO BE 4 SCHEDULE 40 P.V.C. SET LEVEL FOR AT
-,- Schedule 4� P w i
10 min. from PVC /Charcoa Odor Frlttr � 1 �s : t
, l SYSTEM
SYS - � .
`house o se trc Conk ROFILE .YIE� 0 F LEACHING :. - . - , ,
ExistingFoundation a - s ouTLFT - s
s tc tank coven must be }ept Ir1 KNOCKOUTS !
withinn fgrade
6 r . o i>Niedsx, <fin I
aS a a
Grade over tic Tank 98.00 r adeover SAS ELEV- 97.75 . . _ �.-_.,.
',.
�D Glade over D Box 98.00 . ., .-'. �d .f tp I/z tdw!AwMowe 5.5 tr INLET
/i to r �z rw,a saer. 1 �� r' a Ra r r.
! OUTLET 1 ,< ., .. I »'
j`t_f"` Jr�
f
0..
i E o
f
S s r �//N
A,02
3 HOLE H 10
$ " { »
10 _ 5.5 s "8 ,t 1
40 T i,
T 3 maximum Ta of SAS Elev, 94. 5 4 SCH, t.7S � l t
.+ OR Dis . BOX kn Covar P 7 JJ . }t r
- t NEW GREATER • c 3 v$0 S� 0.010 per foot c
_ _D a
0Ll.P500 GAL.. 0 0 caCROSS-SECTION $ ... � o �
o . �
/ f PLAN SECTION
n 'o ra o
SEPTIC TANK • � .? >r ,� � �,
r i
p 1 c7 M 20 Effective
;:L-- f
/ rnM O m o a
'o o ' � a *w .
:.a N _a _ �. .. f. .n
25.5 t � .
t>o.s.n. cA 3 DrJts Q 8 S r
/ - tt
o t o
d , i ✓
FnuNMTi�
9 t 1';:.FULL st O _
25.5 3z DISTRIBUTION 'BOX
� _ e � m .� 3.2 . 3 HOLE H 10 D
rn o
or > _ - t6o -rw r-
M 4 N #y rw o t o b NOT TO SCALE
6 1n.ot 3 4 t 1 >
_ / I -: 32 mY>�4?si�fnata�ar# v�.�•
SYSTEM ippROFtLE > -r -~
L > compacted e ` ?> u • •' Effective hen th , r � $
� p atom > d � ® 13 N' 9
Not to Scale - .... c ,. _ Effective Mldth".. . . ....
>
_ SYSTEM (SAS) GENERAL NOTES
ES`
-c c > _ SAIL ABSORPTION S V R
- n
_ WI GINS PRECAST responsible for Di safe notification
-_ - 500 C;; 10 LEACHING UNITS / G 1. 'Contractor is resp n Dig
safe in.of 3/4 1 1/2 0 _, .
utilities and pipes.
compacted wane m and protection of all underground, P P
P
- Not to Scale
i box shall be set
NOTE. ALL COMPONENTS MUST HAVE RISERS TO WITHIN 8 BELOW GRADE 2. The e tic tonk and distrl ut on
Bottom'of Test Hole 1 Elev.-86.00 P ,,
-,level on 6 of -3 �j2 stone.
_ J
Obs. Groundwater Test Hole 1 Elev.- NONE-OBSERVED ,
,__-. .-- 3. Backfrll should be clean. sand or gravel .with no
" ,
stones over 3 m size.: '
4. This system is subject to inspection during installation
PROJECT BENCH MARK Y 1 _ P
- '. Environmental Services Inc... .
FOUNDATION by_Carmen E. Shay Env r ,
1 TOP OF FOUND N
i accordance
? ...,- 5. The contractor shall install this system n acco d
LOT 80
LOT 72 LOT 73 ELEV. 100.00 Assumed #
# # r � ) with Title V of the Massachusetts .state cede; the approved plan
-PERCOLATION
TEST
-
and Local., Regulations::
__--- installation" he co tractor encounters an
1 6. If, during t n y
f Percolation Test: MARCH 31 2005
Date a �---- ,
t soil conditions or site conditions that are different
Test Performed.B CARMEN E. SHAY, R.S., C.S.E. „
140.49
�" � 1 4 PVC Failed _ from those shown on the soil log of in our design
.OH. r • 1
Results Witnessed By. WAIVER (per BARNSTABLE B ) 1
t Vent Pie i �-� Cesspool ' � installation must'halt & immediate notification be
6 P _ C P Failed
Excavated B SHAY ENVIIRONMENTAL SERVICES 'INC. i � -_D Box .
Y ! 1to Carmen 'E. Shay,,- Environmental Services; Inc.
Cesspool , made
P r a , I •. r 1
Percolation Rate:.` Less Than <2 M I
i t � 7. No`vehicle or heavy machinery,shall drive over the
•w�• YY
1 O O -
� ` 0 septic system m unless. hated:as H 20 septic components.
I 1 13 • • • __ p y e P P
i 1 ! -- . . •r 98
O 8. Install Tuf-rite `as baffles orequals on all outlet. tee`ends.
_�� . =
Test Nola < �9 I � �r.�_s �- -T_._ ._ . . _ n hall be 4 .diameter .Schedule 40 NSF PVC pipes.
1 r ��. I NEw t5oo I Nat-i�af 6es L-+rie 9. All Distribution Lines s P P
! t 1 -- 9a
N o. 1
� ! ! 32 Septic Tank - 10. All solid piping, tees & fittings shall be 4 diameter '
DEPTH 5i0iLS ELEV. '
i 1Failec.
f Schedule 40 NSF PVC pipes, with water tight joints.
_ .TEST HOLE 1 , l i � ,-- P P 9
0 98.00 !
Cesspoo
! Connected to ALL OF The Residence and Abutting
, t ELEV 98.00 11. Municipal ..Water is Co g
Sandy
c Properties Within 150 Feet.
Uoam I ASPHALT I 1 P
! t
. . LOT 71 DRIVEWAY EXISTING
1D YR sj2 , # i 1
0 -8 A 97.25 ! , , 4 BEDR00
I THE PROPERTY LINES ARE APPROXIMATE AND
i Loamy 1 1
HOUSE & 404
I 1 COMPILED FROM THE :SURVEY PLAN GENERATED BY
Sand i 1 1 BEARSE & KELLOG, BARNSTABLE, MA ENTITLED
, I 1 CONCRETE SLAB:
10-"fR 5/6,: - __- -`� 1 I •• 17786-E
FOUNDATION SUBDMSION PLAN OR LAND IN BARNSTABLE, MA LC
B 95.75
e - t t 1 p DATED MAY<21, 1954. IT SHOULD BE USED FOR NO PURPOSE
I }
Med.
OTHER THAN THE SEPTIC SYSTEM INSTALLATION.
SAND
{ I 1 p p r co
( 2.5 Y 7/4 .., O 5- 1 O
• :` .� I
i EXISTING LEACH PIT/CESSPOOLS TO BE PUMPED OUT AND
ASPHALT I
I 1 I LOT #57 FILLED IN PLACE OR REMOVED TO FACIUTATE INSTALLATION OF NEW SAS.
DRIVEWAY
00 11,500 Square Feet +�
LOT #56 NOTE,. ANY STRIPPED OUT SOIL CONTAINING `LEACHATE
- \ t FROM THE EXISTING LEACHPIT/ CESSPOOLS TO BE DISPOSED
! 3 9 f OF AS PER ;BOARD OF HEALTH SPECIFICATIONS.
f
5
�WF n n nC : R W 7 i7 n H POP RTY
_ _ •, N0 .._._.(`._� A..E PR_.,ENT .,ITHIN __0. _F THE R E
--- -
r ASSESSORS MAP 292, PARCEL 160
Perc #1 „ LEGEND
Depth to Perc: 40 to 58 1 j \
Perc Rate= Less Than 2 MPI
r �
DENOTES PROPOSED
Observed ESHWT® - NONE OBS.- 144 Assumed i
i r'- --�\ �� 104X1
ADJUSTED H2O Elev. = NONE OBS - 144" Assumed I �n� .e ri�na i SPOT GRADE
t ASPHALT \�
LOT #70 DRIVEWAY , LOT .#58 / ,` DENOTES EXISTING
X 104.46 SPOT GRADE
} i PL PROPERTY LINE
I 1 I 0r� PROPOSED CONTOUR
I ,
EXISTING CONTOUR
I i
3-24- DIAkk ACCESS MANHOLES I I i , I DEEP TEST HOLE &
TO• -6" I ! i PERCOLATION TEST LOCATION
6 FOOT STOCKADE FENCE
INLET el
in
REV:, Lowered Elevation of Soil Over SAS (3 Max Cover per BOH)
/ ou EtINLET -.- �.. � I
THE ACCESS COVERS FOR THE SEPTIC TANK,
z_ P LOT P LAN
LEACHING COMPONENT
•t,-.• .•-- -;_ -.,•.,.-r.---.- ,---� DISTRIBUTION BOX AND C
SHALL BE RAISED TO WITHIN 6" OF f
STEEL REINFORCED PRECAST CONCRETE FINISHED GRADE. PROPOSED M F 1
INSTALL TUF-TITE GAS BAFFLES OR EOUALS
- �?F RO OSED SEPTIC SYSTEM UPGRADE
PLAN VIEW ON ALL OUTLET TEE ENDS
1 PREPARED .FOR
v veRs 3-24 REMOVABLE CO ..
H 4" TO CUT OWN FROM XIS GRADE OVER AS< 3 FEET MAXIMUM COVER-PER B(0 BE D EXIST. S --
_ _ K� RSTEN ECKARD
-_ a_. _ a
- - AT
V min..clearance -`, 13' ".ET -
INLET
`. 8• min j2 .,trdrt. kilet to outlet 8.- h #4e2
_
--8 EA R S E S WAY
_.._ �' OUTLET
T I Li-44
1 .
�$ HYAN N I S MA
E.-, !I * -- 4'-a"min:
v- or nsn. Lqukl depth J G L
op Design Calculations ,� (A
o
Number of Bedrooms: 4 Bedroom EXISTING � � N OF Mq PREPARED BY:
•• • :�.. • :•-»_ _ .. ._:._ ,-:-•; Garbage Grinder. No _
qc..
^ s _6• " Ca acit d: 440 Gai. Da MIN. PER TITLE V M::¢ u �T
tD o Leaching Y S lA l
- XIS 1 000 GAL. Septic Tank. E.-
CROSS Se ik 2 x 440 Gal.__Da 8 T. _, ,S P o
CROSS SECTION END SECTION
SOIL ABSORPTION AREA. Using percolation rate of [2 min: me 40 � H EN RONMENTAL SERVICES, INC.
9 p 0 20 5
= 07.84 gallons 0
Bottom Area. 0.74 gal/sq- ft. x '416 sq. ft. 3 g �
f .,- 1 .2 gallons <7,, .� X 627
Sidewoll Area. 0:74 gal.%sq., ft. x 180 sq. t 33 g (_
TYPICAL 1500 GALLON' SEPTIC TANK �.r
Providing: = 441.04 gallons o}sTE�- EAST FALMOUTf- MA 02536
c s.♦s � r
h P
NOT TO SCALE
,,,_ NITa
11 1.
Use. 3 PRECAST 500 C UNITS, HAVING A.2 EFFECTIVE DEPTH, ` „ > „. _ : _;,.;,�:- TEL FAX 50$ 548 0796
B USED WITH 4 OF WASHED%STONE ON THE 51dE5 AND
SCALE. 1 20
>,
H 10 LOADING To E • � ,
1 -- DRAWN BY. CES DATE_ APRIL 1 2005
3.25' OF WASHED STONE ON THE ENDS. SCALE. 2O W ,
F 1
PROJECT SD716 FILENAME. SD716PP:DWG SHEET 1 O
- - All OUTLET PIPES FROM THE
VENT PIPE (O Least 24 inches toll) - SECTION A -A " ALL OUTLET
BOX SHALL BE
10' min. from NOTE: ALL PIPES ARE TO BE 4• SCHEDULE 40 P.V.C. Schedule 40 PVC w/Chorcool Odor Filter SET LFVEL FOR AT LEAST 2 FT. ul-11
• CONCRETE COVER
Existing Foundation I house to septic tank: PROFILE VIEW OF LEACIIING SYSTEM Septic tank covers muat t>e _ - �� 3 5'.OUTLET- KNOCKOUTSwithin 6 Tn. of fmrshed grade Grade over Septic Tank - 9&00 Grade over D-Box - 98.00 ode over SAS - EEV= 97.754• � r t/s ►.rya tva.e.t StwvSS OUTLET 12" MLET �i> nLA
S 3 HOLE H-10 -S=0.10 ' ._ •.,:." 2
10' EXIST. OR GREATER DIST. BOX 3' Maximum Cover Top of SAS-Etev.=94.75 -15.5'---
a Si* 0.010' per foot • 4" - SCH. 40 Te t.75' �% I Z x ;?.x o 1,000 GAL. - - } -o, c- -0 0.. o CD 0 _ _ . I; §'. .'E F -
w O SEPTIC TANK to'
ED 0 0 0 C3 a PLAN SECTION CROSS-SECTION
�; + ;
II rn H-10 0 o r) 20' o Effective Depth o o'o 'o 0
> o.eerw rn .t a o 0 0 3 L"ts 2 8.5' -_ 25.5' ;
FULL FovNDA _ u 0 3z5 _---25-5 3.2 3 HOLE H-10 DISTRIBUTION BOX '
g m II it 4'- 5 4
SYSTEM PROFILE 6 ln.of 3/4"-1 1/2" m '
]1�' .J Obit m,... .aro NOT TO SCALE �compacted stone 13'-'- II Effective Length 04041P'Awd 44 AC.awx, O6)2. FtJfEvNot to Scale Effective WidthpIcv SOIL ABSORPTION SYSTEM (SAS) GENERAL NOTES
6 in.of 3/4--1 1/2• 0 500 C H- O LEACHING UNITS / WIGGINS PRECAST 1. Contractor is responsible for Digsafe notification
compacted stone m Not to Scale and protection of all underground utilities and pipes.
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE Bottom at Test Hole 1 Elev.-86.00 2. The septic tank and distribution box shall be set
---------------------- ------- ----
Obs. Groundwater - Test Hole 1 Elev_= NONE OBSERVED t^ 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 '
'- 1 i with Title V of the Massachusetts state code, the approved plan
r ( and Local Regulations,
I
Date of Percolation Test: JUNE 3, 2005 j I 6. If, 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
i Results Witnessed By. WAIVER (per BARNSTABLE B.O.H.) I from those shown on the soil log or in our design
i
i Excavated By SHAY ENVIRONMENTAL SERVICES, INC. i installation must halt & immediate notification be
Percolation Rate: Less Than <2 MPI I 1 made to Carmen E. Shay Environmental Services, Inc.
LOT #56 1
LOT #83 It 7. No vehicle or heavy machinery shall drive over the
I t septic system unless noted as H-20 septic components.
#404 I 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends.
Test Hole Test Hole 1
--- 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVCpipes-
No.
1 No. 2 LOT #57 98 �" 4" PVC i ��
._.___1__'' _ - _ Vent Pipe\ 10, All solid piping, tees & fittings shall be 4" diameter
DEPTH SOILS ELEV. DEPTH SOILS ELEV. '
D 98.00 D 97:85 TEST HOLE Failed i Schedule'40 NSF PVC pipes with water tight joints.
Sandy sandy ELEV = 97.85 I LEACH PIT 11. Municipal Water is Connected to ALL OF The Residence and Abutting
to YR 3/z to YR 3/2 --Loom Loom 72.66 i Properties Within 150 Feet.
0"-8" Ao 97.25 0"-10" A, 97.00 LOT #55- 1 1
Loam Loam 13' 1 34.5' THE PROPERTY LINES ARE APPROXIMATE AND
Sandy Sandy �� 11,500 Square Feet +/- .I COMPILED FROM THE SURVEY PLAN GENERATED BY
10 YR s/s 10 YR s/e �9, I I^`�� i w i BEARSE & KELLOG, BARNSTABLE, MA ENTITLED
e'- 40" e. s4.ss 1D'- 38" a„ sa.sa L I ,I \1 i w I "SUBDIVISION PLAN OF LAND IN BARNSTABLE, MA" LC 17786-E
t I > I DATED MAY 21, 1954, IT SHOULD BE USED FOR NO PURPOSE
Med. Med. L } 4 I OL t OTHER THAN THE SEPTIC SYSTEM INSTALLATION.
SAND SAND
I i I O 1
2.5 Y 7/4 2.5 Y 7/4 - - - ' IL • F32'1
l I 1 0 CC) ASPHALT
s.00 85.85 1 - 9 ASPHALT
�40"- 144 C i38"- 144 C
DRIVEWAY DRIVEWAY I EXISTING LEACH PIT T PUMPED T A
i 1 1 I O BE U ED OUT AND
�� f:= • d i i REMOVED TO FACILITATE INSTALLATION OF NEW SAS.
r - I
I NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
LOT >'#84
_ �:�� � I 1
-- -�- _ ._ _. - - _ � _ _ __ __ _ _._ -- ____ _. _ FROM .HE _Xb5TWG LI=ACH- 1T_- TO BE DISPOSED _
i Exist. 1000 al.
� EfiISTIlbr�- --f0.5�--r t � 9 r
_ _ _ 0. ..AS -PEER ;
4 \ 4 BEDROG tf.#; I Septic Tank 1,
,, � BOARD OF HEALTH SPECIFICATIONS:
/ i ( l
HOUSE NO WETLANDS ARE PRESENT WITHIN 200 OF THE PROPERTY
CONCRETE SLAB z i 37.31' i ASSESSORS MAP 292, PARCEL 158
Perc #1 \\ �t FOUNDATION PL
Depth to Perc: 40 to 58" \t ti r.".!)
1 LEGEND
Perc Rate= Less Than 2 MP1 � II -----------------------------------
Observedu
ESHWT@ - NONE OBS.- 144" Assumed I ', TEST HOLE #1 DENOTES PROPOSED
ADJUSTED H2O Elev. = NONE OBS. - 144" Assumed i 1 ELEV = 98.00 PROJECT BENCH MARK 104X1 SPOT GRADE
1 i TOP OF FOUNDATION
__ _ ELEV. = 100.00 (Assumed) x 104.46 DENOTES EXISTING
68.00' I I SPOT GRADE
• I I LOT #54
i I PL
rox_Municipal Watet Lin oe PROPERTY LINE
1
LOT ##53 - � 6P PROPOSED CONTOUR
I
- - - - -97 EXISTING CONTOUR
1
�� DEEP TEST HOLE &
2-18' DIAM. ACCESS MANHOLES I - -
e, I i PERCOLATION TEST LOCATION
1
# 6 FOOT STOCKADE FENCE
Jl 1 I PLAN
OU ET1P LOT
-� �•` THE ACCESS COVERS FOR THE SEPTIC TANK, I
DISTRIBUTION THAN AND LEES BELOW COMPONENT I 0 E PROPOSED SEPTIC SYSTEM UPGRADE
SET DEEPER 7NAN 6 INCHES BELOW FINISHED I
. -: =• •.Y j ' •�•.,. ." GRADE SHALL BE RAISED TO WITHIN 6' OF - I I
FINISHED GRADE. � L PREPARED FOR o�t /s�,
STEEL REINFORCED PRECAST CONCRETE I l
PLAN VIEW INSTALL TUF-111E GAS BAFFLES OR EQUALS 7 L R O SA E S M A E L 2-
3-24- REMOVABLE COVERS �� -
---------
AT
r. .., _ 4" >.- ,S' yjrA Y # 3 9 B EA R S E S WAY
•` .3• min. clearance I J A-
��
INl£T 8• min_r f 2• min. inlet to outlet 13- INLET•T' _
-- e•mM. (40 'FOOT RIGHT OF WAY)
to min. uqu eval-,. + a�TLET H YA N N i S , MA i
s -r --- + 5' -7• Design Calculations
PREPARED BY:
' E 4'-0" min. Number of Bedrooms: 4 Bedroom EXISTING M
o a o-a•ea. Liquid depth - ,9C
- Garbage Grinder: No
Capacity equire ' 4 0 a Day N PER TITLE V)LeachingR d I./ (MI L � A M /��� �j
Septic Tank - 2 x 440 Gal./pay = 880 USE EXIST. 1,000 GAL. Septic Tank.
1�! 1_ ��� A��� Y
4' -io" SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch ; 0 20 40 50 SH NVIRONMENTAL SERVICES, INC.
CROSS SECTION END-SECTION Bottom Area: 0.74 gal/sq. ft. x 416 sq. ft. = 307.84 gallons
Sidewall Area: 0.74 gal./sq. ft. x 180 sq, ft. 133.2 `gallons � P.Q. BOX 627
I
Providing: = 441.04 gallons s S-T EAST FALMOUTH, MA 02536
TYPICAL 1000 CALLON SEPTIC TANK Use: gNITA?1%
(3) PRECAST 500-C UNITS, HAVING A 2' EFFECTIVE DEPTH, SCALE: 1 "=20' TEL/FAX 508-548-0796
NOT TO SCALE TO BE USED WITH 4' OF WASHED STONE ON THE SIDES AND SCALE: 1 "=2O' DRAWN BY: CES DATE: JUNE 6, 2005
3,25' OF WASHED STONE ON THE ENDS.
PROJECT#SD756 FILENAME: SD756PP.DWG SHEET 1 OF 1
e