HomeMy WebLinkAbout0142 BISHOPS TERRACE - Health 142 Bishops Terrace, Hyannis
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Commonwealth of Massachusetts
vTitle 5 Official Inspection Form -4
d Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
142 Bishops Terrace rti,l
Properly Address
Sandra Megee rct
Owner Owner's Name `C
Information is 0,
required for every Hyannis MA 02601 6-28-18 rip
page. Cityrrown State Zip Code Date of Inspection rat
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 A. General Information ,,,rrrrrtr„
on /-3'3 vf�thecomputer, a�1�`� JiiAOFAfq
l 1 ���
use only the tab 1. Inspector:
key to move your : •. G
cursor-do not James D. Sears : JAMES •:�_
use the return !v
Name of Inspector m u: SEJ�K�1
key. `
Capewide Enterprises '•.o o:
Company Name '7�' -,T r .:�p�`;c
sv
VQ 153 Commercial Street
�NiuSp�G```���
Company Address
Mashpee MA 02649
City/Town State Zip Code
508-477-8877 S1623
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 CM 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6-28-18
actor'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 should be sent to the system owner and copies sent to the
buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins.doc ray.We Title 5 Official Inspection Form:Subsurface Sawago Disposal System•Page 1 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
VVr;,
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information r e Hyannis MA 02601 6-28-18
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E 1 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:
The system is a 1000 Gal. Tank D Box and four chambers.
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):
i5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner owner's Name
quired foti fo isr every reequire Hyannis MA 02601 6-28-18
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpslalarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. System will
pass inspection If(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
15ins.doc•rev.Wl6 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 or 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y 142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information is
required for every Hyannis MA 02601 6-28-18
page. Citylrown 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 %day flow
l5ins.wc-rev.W6 Title 5 Official Inspection Form Subsurface Sewage Disposal System-Page 4 of 17
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Vy. 142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information is required for every Hyannis _ MA 02601 6-28-18
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 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
I.i, a6ed xeJ dH Z 6ZZ 81.02 ZO lnf
Commonwealth of Massachusetts
Title 5 Official Inspection Form
l4 Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information is
required for every Hyannis MA 02601 5-28-18
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): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x*of bedrooms): 330
t5lns.doc-rev.6116 Title 5 OAiciai Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
142 Bishops Terrace
re _
Property Address
Sandra Megee
Owner Owner's Name
information is required for every Hyannis MA 02601 6-28-18
page. CitylTown State Zip Code Date of Inspection
D. System Information
Description:
1000 Gal.Tank D Box and four chamber's.
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection [] Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage(gpd)).
NA
Detail:
Sump pump? ❑ Yes ® No
Last date of occu anc : Present
p Y Date
Com mere lalllndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/personslsq.ft.,etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
15ins.doc-rev.6116 Titie 5 Official Inspection Form:Subsurface Sewage Disposal system-Page 7 of 17
£1, abed xed dH £6ZZ 8 60Z ZO lcl'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
.ulvttr Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
v 142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information is required for every Hyannis MA 02601 6-28-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
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):
15ins.doc•rev.s+is Title 5 Official Inspection Form:Subsurface Sewaae Disposal System-Page B or 17
t,l, a6ed xe:1 dH b I,ZZ ME ZO lnf
Commonwealth of Massachusetts
: Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
requinform
r on is Hyannis MA 02601 6-28-18
requiredd for every
Paw- Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed(if known) and source of information:
1996 Permit # 96-457, 12-2015 New D Box.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 16"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.):
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
Depth below grade: 4
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
yearn
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gal. Precast H-10
Sludge depth:
1"
t5ins.doc•rev.6/16 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Pane 9 of 17
gl, 95ed xed dH t l,ZZ 860Z 20 lnf
Commonw®alth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information is
required for every Hyannis MA 02601 6-28-18
page. Cilyrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29
Scum thickness
Distance from top of scum to top of outlet tee or baffle S
Distance from bottom of scum to bottom of outlet tee or, baffle
18"
How were dimensions determined? Asbut-Tape
Slludgudg e Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank at 4" below grade. Inlet baffle, outlet tee. No sign of leakage or over
loading
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
t5in%doc-rev.6116 Title 5 Otrieial Inspection Form:Subsurface Sawage Disposal System-Page 10 0117
gt ailed xe:1 dH b6:ZZ 860E ZO lnr
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information is required for every Hyannis MA 02601 6-28-18
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle(condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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.doc-rev.8118 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
a6ed xed dH S 6ZZ 81.0Z ZO lnr
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information Is Hyannis MA 02601 6-28-18
required for every -
page. Cityrrown State tip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-3' below grade w)one line out. Box is new 12-2015 w/cover at 6".
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
I
t5ins.doc-rev.6116 Title 5 Official Inspsclion Form:Subsurfsoe Sewage Disposal System•Page 12 of 17
gl� abed xed dH 5VZZ M6 ZO lnf
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information is required for every Hyannis MA 02601 6-28-18
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Typelname of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is four chambers. Ck D Box and camera out to chamber's. No sign of over loading or
solid carry over.
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc-rev.EN6 Title 5 Official Inspection Form:Subsurface Sev.•ago Disposal System•page 13 of 17
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c"y Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information is required for every Hyannis MA 02601 6-28-16
page, CityrTown 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.):
tsns.doc-rev.W16 Tile 5 Officlal Inspection Forrn:Subsurface Sewage Disposal System•Page 14 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
1
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
r 142 Bishops Terrace
Property Address
Sandra Magee
Owner Owner's Name
information is required for every Hyannis MA 02601 6-28-18
page, City/Town State Zip Code Date of Inspection
D. System Information (cont)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
I
t5ins.doc-rev.016 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 15 of 17
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Commonwealth &Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
Information is Hyannis MA 02601
required for every
page. CI ylrown 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
I
A
U f
15ins 3113 Tilk S Official Inspeclon Forth:Subsurface Soweae Disposal Splem•Page 15 of 17
ZZ a5ed xeJ dH 9l.:ZZ 860Z ZO lnf
N Commonwealth of Massachusetts
C', Title 5 official Inspection Form
NSubsurface Sewage Disposal System Form •Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information is Hyannis MA 02601 6-28-18
required for every
page. cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells �p
Estimated depth toi gh ground water: 16+
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 hale 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:
G.W. 15'+off past report 2000.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins.doc rey.6116 T tle 5 Official Inspection Form:Sumuriace sewage Disposal system-Page 16 of 17
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Commonwealth of Massachusetts
� iOfficial Ins ection� T tie 5Form p
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
142 Bishops Terrace
.1 Property Address
Sandra Megee
Owner Owner's Name
information is required for every Hyannis MA 02601 6-28-18
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
i
I
t6ins.doc•rev.6116 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 17 of 17
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e 5
No. j )� 7,41
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
4plitation for Disposal 6pstem ConstrULtioll permit
Application for a Permit to Construct( ) Repair(,"� Upgrade( ) Abandon( ) ❑Complete System ZIndividual Components
Location Address or Lot No. (4d't DiSOdpS TEMAe—l"' Owner's Name,Address and Tel.No.
H�.�JI$ �'f}FlDRA PEtZRZ(
Assessor's Map/Parcel A51 l qX l31 -r, V. ifjjS
Installer's Name,Address,and Tel.No. 576�^*"17-2Tc j'T Designer's Name,Address,and Tel.No.
cAvSW(bs E nal� L4-C-I �� r Si
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 0—0
X'J. S'*C.1_ Sa4a(Tc4" TP
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Sig ed Date l l ;t0 +-AC L`j
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. C;)o 5 —��� Date Issued
THE COMMONWEALTH OF MASSACHUSETTS Entered ineoinputer
A Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS n
application for MisposaY 6pstem Construction 3pErmit
Application for a Permit to Construct( ) Repair(,)� Upgrade( ) Abandon( ) [:]Complete System 'Individual Components
Location Address or Lot No. 1 Lr1 01506PS -CERkAC.E Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel aZ5 f H 1S SANZ)PA PeARY M1=6�FCC-
Installer's Name,Address,and Tel.No. .56'g-4-7 Z•-2'9-7.7 Designer's Name,Address,and Tel.No.
G4PGWtb1- G076Rpa tS6& LZ-C-
17513 6,/A
Type of Building:
Dwelling No.of Bedrooms Lot.S'ize sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers Cafeteria
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
t
Nature of Repairs or Alterations(Answer when applicable) -l3 4K A f n UA-M
<-- �. Zr`15ZDl�C_L_ D4ti1 tToE ft� T�
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Si ed Date l l-eZp —oZ0 t 5
Application Approved by x Date
Application Disapproved by Date
for the following reasons
Permit No. C3* Date Issued \ !;�O
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
�--// Certificate Of Compliance i
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(K) Upgraded( )
Abandoned( )by C(16L41)1 b E
at / �_/ _SNw'PS 'T'�-�D,lQ_ has been constructed in accordance ) G
with the provisions of Title 5 and the for Disposal System Construction Permit No.DO 1 �dated
Installer O4-0� Designer
#bedrooms ) A Approved desi flow A x/ gpd
The issuance o this 11. t shall not be construed as a guarantee that the system will fimc'ori as design Rd.
Date ) �d 4 i Inspector t
R
-------- ---------------------------------
------------------------------
No. ,;)o 6 Fee /ems
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION'-BARNSTABLE,MASSACHUSETTS
Misposal 6ps6m Construction Permit
Permission is hereby granted to Construct( ) Repair(x) Hy
( ) Abandon
System located at _ 1�,� /S f4y-PS' —F6— .�c r t"7 y Jul
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this pe it.
Date � � Approved by
AsBuilt Page 1 of 1
TOWN OF BARNSTABLE
LOCATION O P.S 2ngM SEWAGE 1i
VILLAGE � j(�(s' ASSESSOR'S MAP&LOT /" ?7
INSTALLER'S NAME&PHONE NO. 107. 6,61,49--,K`'7ZJ'. 8 77!
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) �aLf��' (size)f K44-112.���'2
NO.OF BEDROOMS �/� / /
) SR OR OWNER 4iZ40�4f
PERMITDATE: COMPLIANCE DATE-.: 9111
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
fz., on site or within 200 feet of leaching facility) Feet
Edge of Wetland.and Leaching Facility(If any wetlands exist
within 300 feet of ng faci' Feet
Furnished by �+��
P
;aI
v
4
http://issgl2/intranet/propdata/prebuilt.aspx?mappar=251177&seq=1 12/4/2015
(
Dec 08 2015 21:06 Jim The Inspector Man 5085349919 page 18
,_,7 tA7
Comm
onwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
142 Bishops Terrace _ l
Property Address
Sandra Megee
Owner Owner's Name
information is
required for ever. Hyannis MA 02601 12-7-15
page. City/Town Slate 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 and of the form.
Important:When filling out forms A. General Information '
pP ��1uuUlufgq��
on the computer, J `\�������tN OF M,gs3!Oi���
use only the tab 1. Inspector: 0
key to move your
cursor-do not James D.Sears �; JAMES ;.
use the return Name of Inspector ;�„
key,
Capewide Enterprises, LLC =* o
�I Company Name �s,�� IVTrI lz;,� N�
153 Commercial Street giii��r�rStiN Spt`\\\��a
Company Address ,
Mashpee MA 02649
Cityrrown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
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
12-7-15
fAspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP, The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
""This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use. /
I&ne•3113 Title 5 Official Inspeollon Form:Subsurface Sewage Disposal System•Page 1 of'17 tY
Dec 08 2015 21:06 Jim The Inspector Man 5085349919 page 19
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Magee
Owner Owner's Name
information is
required for every Hyannis MA 02601 12-7-15
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:
The system is a 1000 Gal. Tank D Box and four chambers.
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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Dec 08 2015 21:06 Jim The Inspector Man 5085349919 page 20
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information is required for every Hyannis MA 02601 12-7-15.
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumpstalarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5in3•M3 Title 6 Official Inspection Form Subsurface Sewage Disposal System•Page 3 or 17
Dec 0$ 2015 21:06 Jim The Inspector Man 5085349919 page 21
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information is
required for every . Hyannis MA 02601 12-7-15
page. City(rown 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 coeeepW is less than 6" below invert or available volume is less
than %Y day flow .4
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pape 4 of 17
Dec 0$ 2015 21:06 Jim The Inspector Man 5085349919 page 22 {
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
ion is
requirequiredd for every Hyannis MA 02601 12-7-15
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 falls. 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 16.304.The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sage Disposal System•Page 5 of 17
I Dec 08 2015 21:07 Jim The Inspector Man 5085349919' page 23
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i•
142 Bishops Te
rrace
Property Address
Sandra Megee
Owner Owners Name
information is
required for every Hyannis MA 02601 12-7-15
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health !
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
® 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 NIA)
® ❑ 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)1
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 at 17
Dec 08 2015 21:07 Jim The Inspector Man 5085349919 page 24
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments j
142 Bishops Terrace
a
Property Address
Sandra Megee
Owner Owners Name
information is
required for every Hyannis MA 02601 12-7-15 '
page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal. Tank D. Box and four chambers
Number of current residents: 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use?
El Yes ® No
Water meter readings, if available (last 2 years usage(gpd)): NA
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Present
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•3113 Title 5 Official Inspection Fovrt Subsur►aos Sewage Disposal System•Page 7 of 17
Dec 0$ 2015 21:07 Jim The Inspector Man 5085349919 page 25
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owners Name
information is Hyannis MA 02601 12-7-16 required for every y '
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: 5/31112
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 We 5 Official Inspeation Forth:Subsurface Sewage Disposal System•Page 8 of 17
Dec 08 2015 21:07 Jim The Inspector Man 5085349919 page 26
i'
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments '
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information is
required for every Hyannis MA 02601 12-7-15
page. City/rown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1996 Permit*96-457, 12-2015 New D Box.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 16"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.):
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
Depth below grade: 4"
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: 1000 Gal, Preecast H-10
Sludge depth:
t5ins•3113 Title5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 o1 17
Dec 08 2015 21:07 Jim The Inspector Man 5085349919 page 27
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments l
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name 1
information Is required for every Hyannis MA 02601 12-7-15
Page. CitylTown
State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank (cant.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
0"
ll
Distance from top of scum to top of outlet tee or baffle t3
Distance from bottom of scum to bottom of outlet tee or baffle
18"
How were dimensions determined? Asbuilt-Tape,
Sludge Judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank at working level. Tank at 4" below grade. Inlet baffle, outlet tee. No sign of leakage or over
loading.
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: late
t5ins•3113 TRIe 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
i
Dec 08 2015 21:07 Jim The Inspector Man 5085349919 page 28
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
142 Bishops Terrace j
Property Address
Sandra Megee
Owner Owner's Name
Information is Hyannis anni5
required for every y MA 02601 12-7-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(ion 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):
i
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-3113 Title 5 official Inspecion Form:Subsurface Sewage Disposal Syslam-Page 11 of 17
Dec 0$ 2015 21:08 Jim The Inspector Man 5085349919 page 29
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
Information is
required for every Hyannis MA 02601 12-7-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-3' below grade w/one line out Box is new 12-2015 w/cover at 6"
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3113 Titla 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Dec 0$ 2015 21:08 Jim The Inspector Man 5085349919 page 30
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
tt :I
142 Bishops Terrace {
Property Address
_Sandra Megee
Owner Owner's Name
information is required for every Hyannis MA 02601 12-7-15
_ Y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is four chambers. Ck D Box and camra out to chambers. No sign of over loading or
solid carry over.
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
ISns•MI Title 5(Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
l
Dec 08 2015 21:08 Jim The Inspector Man 5085349919 page 31
{
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owners Name
information is required for every Hyannis MA 02601 12-7-15
page, City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3r13 Title 5 Official Inspection Form:Subsurface Sewage Disposed System•Page 14 of 17
Dec 08 2015 21:08 Jim The Inspector Man 5085349919 page 32
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1
w 142 Bishops Terrace
Property Address
Sandra Megee
Owner Owners Name
information is required for every Hyannis MA 02601 12-7-15
page- City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:.
® hand-sketch in the area below
❑ drawing attached separately
RE e
- -.3
v
I5ins-3113 Title 5 Official InspecJon Form:Subsurface Sewage Disposal Syslem•Page I5 of 17
Dec 08 2015 21:08 Jim The Inspector Man 5085349919 page 33
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
Owner Owner's Name
information is
required for every Hyannis MA 02601 12-7-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar '
❑ Shallow wells
tvo
Estimated depth t igh ground water: 15+
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:
1
You must describe how you established the high ground water elevation:
G.W. 15'+ off part report 2000.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
15ins•3111 Title 5 Official Inspeclion Form:Subsurface Sewage Disposal System•Page 16 o117
Dec, 0� 2015 21:08 Jim The Inspector Man 5085349919 page 34
Commonwealth of Massachusetts i
i
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
142 Bishops Terrace
Property Address
Sandra Megee
i
Owner Owners Name
information is
required for every Hyannis MA 02601 12-7-15
page. Cltyrrown 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 System s).completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
a
'I
1
(Sins 3113 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Page 17 of 17
C0.l1.110\-"7EALTH OF MASSACHUSETTS
EkECL''TINTE OFFICE OF ENVIROXME:\TAL AFFAIRS
= F DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREE'. BOSTON DLL 0210c 161" 292550i
TRIC.DY CORE
Secretan
ARGEO PALL CELLtiCCI DAVID B STP.:'HS
Governor Cotnaussioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
PropertyAddress:142 Bishops Terrace Name of Owner Randy Gardner
Date of Inspection:
Hyannis Address of Owner:
Name of Inspector:(Please Print)WM. E . Robinson Sr.
1 am a DEP approved systeM inspector rsuant to Section 15.340 of True 5(310 CMR 15.000)
Company Name: WM. E . Robinson gleptic Service
Mailing Address: PO Box 0 9. Centerville . MA
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site:;asses
ge disposal systems. The system:
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails /� l
Inspector's Signature: �l/ L Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
ti
rev1sed Page Iof11
i
� -•^red o^Rec,¢;rd Pam,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM +
PART A
CERTIFICATION (continued)
'rop"Address: 142 Bishobs Terrace , Hyannis
Ownw: Randy Gardner
Date of inspection:
INSPECTION SUMMARY: Check 08, C, or D:
A. SYSTEM PASSES:
V/ I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. S TEM CONDITIONALLY PASSES:
One or more system components as described in the "Condit.onal Pass" section need to be replaced or repaired. The system, upon
completion of the replacement or repair,as approved by the Board of Health, will pass.
Indicate s, no, or not determined (Y. N, or ND). Describe basis of determination in all instances. If "not determined', explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty (20) years prior to the date of the inspection: or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if lwith approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised; 9/2/98 Page 2of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 14.2 Bishops Terrace , Hyannis
Owner: Randy ardner
Date of Inspection: � G.
C. FU THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
C nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
pu lic health, safety and the environment.
1) SY TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES W ACCORDANCE W TTH 310 CMR 15.303 1111(b)THAT THE SYSTEM
IS OT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) S STEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
NCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) THER
revises 5 2 96
Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATIDN (continued)
Prop"Address: 142 Bishops Terrace , Hyannis
Owner: Randy Gardner
Date of Inspection:
D. SYSTEM FAILS:
You mu)No
icate either "Yes" or "No" to each of the following:
ve determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
rmination is identified below. The Board of Health should be contacted to determine what will bi necessary to correct the failure.
Yes Backup of sewage into facility or system component due'to en overloaded orclogged 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 112 day flow.
_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LARG SYSTEM FAILS:
You must i dicate either "Yes" or "No" to each of the following:
T e following criteria apply to large systems in addition to the criteria above:
he system serves a facility with a design flow of 10,000 gpd or greater(Large System) and the system is a significant threat to public
ealth and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owne or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of Department for further information.
revised 9/2/98 PaRr4ofII
. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART B
CHECKLIST
P.opertyAddress: 142 Bishops Terrace , Hyannis
owner: Rand.v Gardner
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or 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 NIA.
_ The facility or dwelling was inspected for signs of sewage back-up.
_ The system does not receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
v _ All system components, excluding the Soil Absorption System, 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 Soil Absorption System on the site has been determined based on:
// _ Existing information. For example, Plan at B.O.H.
v _ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
f1.5.302(3)(b))
_ The facility owner land occupants,if different from owner) were provided with information on the propermaintenaacii-0f
SubSurface Disposal Systems.
it
re.Lsed 9j2 98 Page 5of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
►rop"Address: 142 Bishops Terrace , Hyannis
Owner: Randy Gardner
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:c15U g.p.d./bedroom.
Number of bedrooms(design):, Number of bedrooms(actual):
Total DESIGN flow 0
Number of current residents:
Garbage grinder(yes or no): a
Laundry(separate system) (yes or no):40; If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no): ALO
Water meter readings, if available (last two year's usage(gpd): 1999 123 , 750 gal'
Sump Pump (yes or no):A., 1998 123 , 000 gal.
Last date of occupancy:
COMM CIALIINDUSTRIAL:
Type of a tablishment:
Design flo gpd ( Based on 15.203) ✓
Basis of d ign flow
Grease tra present: (yes or no)_
Industrial aste Holding Tank present: (yes or no)_
Non-sanita y waste discharged to the Title 5 system: (yes or no)_
Water me r readings, if available:
Last date of occupancy:
OTHER: I escribe)
Last date f occupancy:
GENERAL INFORMATION
PUMPING RECORDS andoou�ce of information:
System pumped as part of inspection: (yes or no)-&(�
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF�fKSTEM
V Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records;if any)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other ,,//��
APPROXIMATE AGE of all components, date installed fif known)and source of information: Q9O)e
Sewage odors detected when arriving at the site: (yes or no)
revised 9/2/G, Page 6(if 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"Address: 142 Bishops Terrace , Hyannis
OwrW: Randy Gardner
Date of Inspection: S-14 -C--eJ
TIGH R HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate o site plan)
Depth bel w grade:_
Material o construction:_concrete_metal_Fiberglass_Polyethylene_otherlexplain)
Dimension
Capacity: gallons
Design flo gallons/day
Alarm pre ent
Alarm lev I: Alarm in working order:Yes_ No_
Date of evious pumping:
Comme ts:
(condi on of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distribution is equal, eviden of solids carryover, evidence of leakage into or out of box, etc.) -
PUMP CHA BIER:—
(locate on si plan)
Pumps in wor ing order: (Yes or No)
Alarms in wor ing order(Yes or No)
Comments:
(note conditio of pump chamber, condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontimmd)
'rop"Address: 142 Bishops Terrace , Hyannis
Owner: Randy Gardner
Date of Inspection: —d—C)
BUIL ING SEWER:
(Local on site plan)
Depth b low grade:_
Material of construction:_cast iron_40 PVC_other(explain)
Distant from private water supply well or suction line
Diamet r
Comm nts: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
llocate on site plan)
jl
Depth below grade:
Material of construction:V concrete_metal_Fiberglass _Polyethylene_otherlezplainl
If tank is metal,list age_ Wage
confirmed by Certificate of Compliance_ (Yes/No)
Dimensions: '� x'
Sludge depth: 9—4 '� I
Distance from top of sludge to bottom of outlet tee or baffle: L
Scum thickness:_
Distance from top of scum to top of outlet tee or baffle: 3 r
Distance from bottom of scum to bottom,,qf outlet tee or baffler
How dimensions were determined: JIL
'omments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.) 40 4
GREA TRAP:
(locate on ite plan)
Depth belo grade:_
Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensio
Scum thi ness:
Distance from top of scum to top of outlet tee or baffle:
Distant from bottom of scum to bottom of outlet tee or baffle:
Date last pumping:
Comme ts:
(recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structurel integrity,
evident of leakage, etc.)
—42
revised .9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'ropertyAddress: 142 Bishops Terrace , . Hyannis
Owner: Randy Gardner
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): v
(locate on site plan, if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number,_
Altemative system:
Name of Technology.:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
cFss ool s:_
(locate n site plan)
Number d configuration:
Depth-top f liquid to inlet invert:
7epth of s lids layer:
)epth of sc m layer:
Dimensions f cesspool:
Materials of onstruction:
Indication of groundwater:
inf ow (cesspool must be pumped as part of inspection)
Comments *-
(note con on of soil, signs of hydraulic failure, level of ponding. condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materials f construction: Dimensions:
Depth of s lids:
Comments
(note con tion of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
rev see 5/L; 7C Pagc9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Nop"Address: 142 Bishops Terrace , Hyannis
)caner: Randy Gardner
.)ate of Inspection: 5!G—b-O
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks car benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
P
�V
A—
V,
)
)
revised 5;2/9R Page 10o;11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
' SYSTEM INFORMATION(contnued)
loP"Ad&ess: 142 Bishops Terrace , Hyannis
Owrter: Rand.v Gardner
Date of Inspection: S`fG 4—
NRCS Report name
Soil Type_
Typical depth to groundwater
/ USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow
Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells Estimated Depth to Groundwater l6' ^'Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)
r"
revises 9/2/96
Pave 11 of'lI
JL0VVN OF BARNSTABLE �
LOCATION 14 S- SEWAGE # "0�'
VILLAGE _ td�lB��� ASSESSOR'S MAP & LOT95�/—17 7.
INSTALLER'S NAME&PHONE NO. lvo?. dd1X5®e—77f S-77i ;
SEPTIC TANK CAPACITY
LEACHING FACII.TTY: (type) (size) 'i���� ��2
NO.OF BEDROOMS , l
B&ffl;MR OR OWNER
PERMTTDATE: 9YI114, COMPLIANCE DATE: `
Separation Distance Between ihe:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of Jea#ng faci� /f� Feet
Furnished by �� '
Q
No. /4�` q5-) Fee 40 .00
-it:. s
°=SHE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
0ppYication for Migpogar *pgtem Cougtruction Permit
Application is hereby made for a Permit to Construct( )or Repair( x)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
142 Bishops Terr Hyannis Charles Chandler
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
W.E. Robinson Septic Sery
P.O. Box 1089
Type of Building:
Dwelling No.of Bedrooms 3 Garbage Grinder( np
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil gravel/sand
Nature of Repairs or Alterations(Answer when applicable)
install 4 stonepacked
infiltrators
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this arc
f Health. Q /
Signed Date
Application Approved by Date
Application Disapproved for the following reasons
Permit No. 9 6— 4��? Date Issued
R Fee E
it !6O MONWEALTH OF MASSACHUSETTSAll v �N
PUBLIC HEALTH DIVISI6N -TOWN OF BARNSTABLE., MASSACHUSETTS`/
Zippfication for Oigpooar *pgtem Congtruction Permit
i
Application is hereby made for a Permit to Construct( )or Repair( x)an On-site Sewage Disposal System at:
Location Address or Lot No. Owner's Name,Address and Tel.No.
142 Bishops Terr Hyannis Charles Chandler
Assessor's Map/Parcel
In 1 's N e, dress,and Te No., Designer's Name,Address and Tel.No.
. ob�nson beptic Sery
P.O. Box 1089
I
Type of Building: 3 np R
' Dwelling No.of Bedrooms Garbage Grinder( 1
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title - _.... 1
Description of Soil
gravel/sand j
���� ��ss install 4 stonepacked
NaVmf�l a atoX Alterations(Answer when applicable)
1 ,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
Cate of Compliance has been issued,by this az f Health: Q /
Signed Date
Application Approved by Date
Application Disapproved for the following reasons /
Permit No. G �s / Date Issued p— if
Chandler THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal._,a� A l�d 6oAorsr qMe on
by Installer
at 142 Bishops Terr Hyannis has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Constructio P. Z dated
Date Inspector
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THY THE SYS-
TEM WILL FUNCTION SATISFACTORY.
No.--- _-------.------------.-----------Fee 40.00
Chandler THE COMMONWEALTH OF MASSACHUSETTS `
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Oigpogat 6potem Cow5trurtion hermit
Permission is hereby granted to W•t• Robinson Septic Service
to construct( )repair( an On-site Sewage System located at No.# 14 2 Bi shops Terr
Hyannis
Street
and as described in the above Application for Disposal System Construction Permit.
No. Date
The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions.
All construction must be completed within three years of the date below. n
Date: Approved by C/� L ell
Board of Health
!i
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT(WITHOUT DESIGNED PLANS)
I, W.E. Robinson SR , hereby certify that the application for disposal works
construction permit signed by me dated , concerning the
property located at 142 Bishops Terr Hyannis meets all of the
following criteria:
• There are no wetlands within 300 feet of the proposed septic system
• There are no private wells within 150 feet of the proposed septic system
• The observed groundwater table is 14 feet or greater below the bottom of the leaching facility
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
1, n
SIGNED: 1 DATE: 711
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
[Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
I
S
I
Zl`
r�.
1
�5
s
No...�.N!------ Fizim...., ,- ....
THE COMMONWEALTH OF MASSACHUSETTS
BOARDfE HEAL H f '
/..............OF...... �
Appliration for Mipos al Works Tunstrurtton Vrrmft
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Sys at:l
.......................................................
a'on-Add ss or of o.
------�------
---
. --------------- 'Z�_k1: ~...
caner -----...---•................................Ad-ress
Installer Address
Type of Build' Size Lot._1 S1- -��.._2__Sq. feet
DwellingpNo. of Bedrooms---------- ............................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures --
Design Flow-------•----_----• U g P P P Y Y O � � gallons.
gallons per person per day. Total daily flow._..........2__________________ ________
M _.Septic Tank Liquid capacity� _gallons Length................ Width.__..._____..... Diameter._._.-._________ Depth___.___._-___
W Disposal Trench—No..................... Width-___--^�,- __ _ Total Length..........
Total leaching area....................sq. ft.
Seepage Pit No../................ Diameter:/�d......Aepth below inlet...... Total leaching area---2_!?_!Zsq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results "Performed by.......................................................................... Date--..'...................................
Test Pit No. 1.....-2 minutes per inch Depth of Test Pit.................... Depth to ground water__._________________.__.
fs Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................
a --•--•. .__..-
O Description of Soil........... Gl�?�_ °+�...__
--- ---------
U
W
U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------------------------------------------- ----------------------- --- .........................................----------
Agreement:
The undersigned agrees to install the afor esc abed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanita . Cod.. —The undersigned further,agrees not to place the system in
operation until a Certificate of Compliance has been is ued by the bRrf hea .,
gne
S Da
lication A roved B = �o�r {j2 27
A %L-----
PP PP Y
Date
APPlicatiori Disapproved for the following reasons----------------•----_-- ------------------------...---•----•-••-----------------••---••--•---••-•--------.
-••--•......•---•-•-•---••------•-•••------------------------••-•---------••-•••---------•-------•••--•.....-----•--•----------------------------------------•-••---•-----•-•--•-•---••------------••----
Date
PermitNo..............................................--........ Issued....................... ................................
Date
A s
No..... o.ZJ...... FEiz............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARDPF H
... 7t .. ............OF..... .. !✓t.i! f> e A
-------- .....................--
Appliratiou for Disposal-i9orkii (banstrur#ion Vrrmit
Application is hereby trade for a Permit t •Construct ( ) or Repair ( ) an Individual Sewage Disposal
S s�er#i at
.,:,a n A ress � r rJ
�yf✓ ,err/, - / ✓�G�' ^..7 f y .�t�l 3L_-{/•' /i�Lc-aH orrLo o y M
Address
t �•�, ` t nerd� Address -
Wr�Gr"rr#',� ------------------••--•--------- ---
Installer Address
Type of Build' Size Lot._-____;!_•_______________Sq. feet
Dwelling—No. of Bedrooms-------------------------------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.-------____-_--_______--__ Showers ( ) — Cafeteria ( )
Otherfixtures-.. I -------•-•-•-•------•--------•---._..... ------d ---------------------
-- A--r'���=
W Design Flow...................................... ,..gallons per person per day. Total daily flow-__-____-__---___-__--_-__-___-----_-_-.-_--gallons.
G. .
W Septic Tank—Liquid capacity�.......___gallons Length................ Width---------------- Diameter........-----_-- Depth---___--_-------
x Disposal Trench No.--__-------------- Width,._._._L_:__ ___. Total Length........ --------- Total leaching area------ sq. ft
�; .
Seepage Pit No_ __________________ Diameter..'.':........... Depth below inlet.__•......._...._... Total leaching area..................sq. f.t.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date--------------------------------------..
a Test Pit No. 1...... _-minutes per inch Depth of Test Pit.................... Depth to ground water........................
f� Test Pit No. 2,...............minutes pej inch Depth of Test Pit-------------------- Depth to ground water----__--_--________----.
Description of Soil...............................................
-�-�-..-------.....---------------------------------------------------------------------------------------------------
x
W ..................................
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
V Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------.
-------------------------------------------------------------------------------------------------------------------------------------=-----------------------------------------------------------------
Agreement:
The undersigned agrees to install the aforedesccribed Individual Sewage Disposal System in accordance with
.the provisions of Article XI of the State Sanitary Cod—The undersigned fur h r agrees no,I to place t e syst m in
"operation until a Certificate of Compliance hash been i sued by the bo f heah.
Signed . -<, ,n��,, ,, _
,� D
Application Approved By...... �' ., �- = � ti , :. .
Da
-
Application Disapproved for the following reasons:...................................................................
------------•-•••••-----•- ......---•••----
-----------------------------• •-•---•-•---•-•-----:..-•--------------•-•--------------------•--------------•--......•-•=---•••---••-••..................---•------- ••--•-------------•---•--•---
Date
PermitNo......................................................... Issued........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD � HEAL
.... !............................OF......... ..
-<!
TI IS TOiERTIFThat tIndrvi u Sewa e Disposal Slstem constructed ( o r Repaired ( )
r t
by y � Mom ;
at ' ---.... ........ . �' s-•- -`------ -- ------. --••---••...---••-•---------•----------------•••--•-'-......•---•----•-- -••--•---•--
has been installed in accordance with the provisions of Article XI of..,The/tate Sanitary Cade d desc ' e(jeG the
application for Disposal Works Construction Permit No-----------------__ •--------------------- dated___ °________ _-----------------------------
THE ISSUA CE OF THIS CERTIFICATE SHALL NOT RE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM V LVFU;lgTjjATISFACTORY.
DATE----------------------- ------------ ----------------••-•-------------------- Inspect = -- �-�G�--.........-•----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ,,QF HEAL,
No.
FEE -•-------------------•
r.
irk, C� rU t rr ti
Permission i hereb ranted_.__..�. ____�.
to Cons�t r`t ( �ror RgT:�i ( ) an�Individ rSewage Disposal-System
at IVo.f l n t. ✓# vrf`._ ,j..�141; e. ---- --•-- -----------
--------------• ----- -------
` Street /- ,
�mit .......... Dated__- ------•-
as shown on the application for Disposal Works Construction e ..=`� -----------
Board V.1th
DATE. =------------------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS '
1 h