HomeMy WebLinkAbout0206 BISHOPS TERRACE - Health 204 BISHOPS,TER. �HYANNIS
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Separation-Distance Between the:
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Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
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within 300 feet of leaching facility) Feet
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 206 Bishops Terrace
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
A. General Information
1. Inspector:
577-�
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
5-16-14
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
510
y
t5 ns 3113 Title 5 OfficiaLV rface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
206 Bishops Terrace
Property Address
Bank Owned (Contact David Holt Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is H annis MA 02601 5-16-14
required for every y
page. City/Town State Zip Code Date of Inspecticn
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:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
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):
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 206 Bishops Terrace
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed- ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
q 206 Bishops Terrace
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to'a surface water supply.
❑ The system has a sept;.c 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
206 Bishops Terrace
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the.SAS, cesspool or privy is below highwground 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.
❑ E 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-
10,600gpd.
❑ ® 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° M 206 Bishops Terrace
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® 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:
h
® ❑ 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): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 206 Bishops Terrace
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is
required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
I Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes M No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (fast 2 years usage (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 4-2014
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease-trap.present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 206 Bishops Terrace
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for 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
h
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
GM , 206 Bishops Terrace
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-16-14
page. CityTrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2000
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 24"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 18
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
12"
Sludge depth:,
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M0 206 Bishops Terrace
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
D. System Information �cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness 3" @ tank outlet
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle 13
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
T W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 206 Bishops Terrace
Property.Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
206 Bishops Terrace
Property Address
Bank Owned (Contact David Hoit @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from chambers.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
206 Bishops Terrace
Property Address
Bank Owned (Contact David•Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is
required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 3-500's
❑ 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.):
Leach chambers in good condition with no sign of back-up into d-box or surrounding stone.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspecbon Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form '
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 206 Bishops Terrace
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
206 Bishops Terrace
Property Address
Bank Owned (Contact David Holt @.Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
i
r _
t5ins-3113. 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
�M 206 Bishops Terrace
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database- explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
206 Bishops Terrace
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 5-16-14
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
I
No.. Fee U
THE COMMONWEALTH OF MASSACHUSETTS I'Enteted to computer: V
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
01pprication for �Wgpool bpg;tem Cone;truction permit
Application for a Permit to Construct( )Repair( v<Upgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. a 06 13/dhOlOS Ty,-y-r' Owner's Name,Address and Tel.Nq.
NY. %eo I�aJSamh.azFh
Assessor's Map/Parcel a j r 7 a c)o( 1 j i r kD r f , r. All.
Installer's Name,AddressAnATI§1''CANCO Designer's Name,Address and Tel.No.
350 Main Street ^/11
W. Yarmouth MA 02673
Type of Building:
Dwelling No.of Bedrooms y Lot Size sq.ft. Garbage Grinder( )
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
Size of Septic Tank Type of S.A.S.
Description of Soil /ne.&O" S,an
Nature of Repairs or Alterations(Answer when applicable) !�A S 441( :3 - $ V_a lea c.� r'hAeM Lc tS'
UU
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 Boar�d PPf eal .
Signed V Date 3"a 1 -O p
Application Approved by Date
Application Disapproved f the following reasons
Permit No. Date Issued
D
- No.-. t Fee
_ THE COMMONWEALTH OF MASSACHUSETTS
4Ent teed��°computer. V
K _ PUBLICHEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS Yes
Application for Migool 6pgtem Construction Permit
Application for a Permit to Construct( )Repair(✓Upgrade( )Abandon( ) El Complete System El Individual Components
Location Address or Lot No.Q O6 /31'Sho/).s Tr r r Owner's N�m e,Address and Tel.No.
>' (ea Kcr�Sowths � ti
Assessor's Map/Parcel a j( /7a i
�106 Aedr /crl, A// .
Installer's Name,Address,*&.Bo.CANCO Designer's Name,Address and Tel.No. L
350 Main Street A//h
W. Yarmouth, MA 02673
Type of Building:
Dwelling No.of Bedrooms y Lot Size sq.ft. `\ Garbage Grinder( )
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
Size of Septic Tank Type of S.A.S.
Description of Soil hre cry. Sax-
. , I
- 42.
Nature of Repairs or Alterations(Answer whenapplicable) 1 n 5 4 1( r S U o l P G C r �,n✓�, c►S
l y r ') /'UYt.� " r u J✓t cam' �is f'j/;
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-
t Cate of Compliance has been issued by this Board pf eal
Signed V f Date
Application Approved by Date
Application Disapproved f r the following reasons
Permit No. Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( 4pgraded( )
Abandoned( )by e c---)
at )a 6 s`U i 1 a 3 r,� 1�e!/' . /�//. has be n construe in ccordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. dated
Installer Designer 0 �{
The issuance of this pe s f�11/ o bereo�used as a guarantee that the syste ill '•unction designe
Date
(1J �/ J Inspector 1 ' '
No. � Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
__1=igpoga1 *pgtem Construction Permit
Permission is hereby granted to Co tract )Repair(grade( b
System located at O 6 /2 ,s A 2. r r
and as described in the above Application for Disposal System Corfstruction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction s be co pleted within three years of the date of thi
Date: Approved by 0,-/ 4 ,
_1/6199
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, �A.yN't, , hereby certify that the application for disposal works
construction permit signed by me dated —a I -moo concerning the ,
property located at c 2y j.> > i y)a as meets all of the
following criteria:
The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
.� • The soil is classified as CLASS,I and the percolation rate is less than or equal to,5 minutes per inch.
/ There are no wetlands within 100 feet of the proposed septic system
There are no private wells within,150,feet of the proposed septic system
There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
/The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
• If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) ?oC
B) G.W.Elevation a3• �o +the MAX.High G.W. Adjustment.Jt q = O�
DIFFERENCE BETWEEN A and B C - 3
SIGNED : d 4. DATE: -- a a v
[Sketch proposed plan of system on back].
q:health folder:cert
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j TOWN OF BARNSTABLE
LOCATIO � r,Sly � �R_ SEWAGE #
VILLAGE 2f+✓44"141 ASSESSOR'S MAP
-& LOT
INSTALLER'S NAME&PHONE NO. /-f ( 4176,? 7 J 7 - boo
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type, :5.0 (size � �X 1.5 X a
NO. OF BEDROOMS '
BUILDER O1 :6;;�., e Q4 ,411�l
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 .
I 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
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Z-,273 502 587 .,
US Postal Service
Receipt for Certified Mail
No Insurance Coverage Provided.
Do not use for International Mail See reverse
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P e,Stale,& IP
Posta $
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Special Delivery Fee
Restricted Delivery Fee
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address leaving the receipt attached, and present the article at a post office service
window or hand it to your rural carrier(no extra charge). �)
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the m
return address of the article,date,detach,and retain the receipt,and mail the article.
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3. If you want a return receipt,write the certified mail number and your name and address
i on a return receipt card,Firm 3811,and attach it to the front of the article by means of the
gummed ends if space pe-nits. Otherwise,affix to back of article. Endorse front of article a
j RETURN RECEIPT REQUESTED adjacent to the number. a
i 4. If you want delivery restricted to the addressee, or to an authorized agent of the O
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5. Enter fees for the services requested in the appropriate spaces on the front of this
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. L`oL
6. Save this receipt and present it if you make an inquiry. 102595-99-M-0079 rA
I
� ,. Town of Barnstable
sr�st� Department of Health, Safety, and Environmental Services
.059 Public Health Division
1679 A��
367 Main Street, Hyannis MA 02601
Office: 508-862-4644 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
TO: TEO RAJSOMBATH DATE: JAN. 20, 2000
206 BISHOPS TERRACE
HYANNIS, MASS., 02601
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL CODE,
TITLE 5.
The septic system owned by you located at 206 BISHOPS TERRACE was inspected on
December 12, 1997, by JOHN GRACI a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of 1995
TITLE 5 (310 CMR 15.00) due to the following:
o "The leaching pit was full. It was past the effective depth of leaching. The soil absorption
system was in hydraulic failure"
U Septic tank was not accessible-located underneath a deck.
The above system, according to our records has been in a failed state for more than two years.
Therefore, you are directed to hire a licensed Town of Barnstable septic system installer to sketch
a proposed system that will bring the septic system into compliance with 310 CMR 15.00, The
State Environmental Code, Title 5 within (14) fourteen days of receipt of this notice.
The septic system must be brought into compliance within (30) thirty days of your receipt of this
directive.
You are also directed to maintain the system by hiring a licensed septage hauler to pump the septic
system to prevent discharge of sewage or effluent into buildings, onto the surface of the ground, or
into surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to any court
of competent jurisdiction as provided for by the laws of the Commonwealth.
P OF BOARD OF HEALTH
as A. McKean, R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
q:he1N�lIIeWtle53y.doc
d SENDER: I also wish to receive the
•a ■complete items 1 and/or 2 for additional services.
in ■Complete items 3,4a,and 4b. following services(for an
% ■Print your name and address on the reverse of this form so that we can return this extra fee):
card to you. ai
d ■Attach this form to the front of the mail lace,or on the back if space does not
d e P 1. ❑ Addressee's Address
■Wpermit. �.
rite'Retum Receipt Requested'on the mailpiece below the article number. 2. ❑ Restricted Delivery N
■The Return Receipt will show to whom the article visa delivered and the date ..
c deuvered. Consult postmaster for fee. °•
3.Article Addressed t : 4a.Article Number
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7.Date of Delivery °
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PS Form 3 0 1, D, ember 199 102595-97-13-0179 Domestic Return Receipt
First-Class Mail
UNITED STATES POSTAL SERVICE Postage&Fees Paid
LISPS
Permit No.G-10
G Print your name, address, and ZIP Code in this box O
f
Public Health Di�ttSlotD
own of Barnstable
P 0. Box 534
riyannis, Massachusetts 02601
i
203 498i 762
US Postal Service
Receipt for Certified Mail
No Insurance Coverage Provided.
Do not use for International Mail See reverse
Sent to j�/
Street&Number /,erlAcci
206
Po ice,State,&ZIP Cbde 02601
Pos ge $
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
LO
rn Return Receipt Showing to
Whom&Date Delivered
n Retum Receipt Showing to Whom,
Q Date,&Addressee's Address
0 TOTAL Postage&Fees $
Postmark or Date
a
Stick postage stamps to article to cover First-Class postage,certified mail fee,and
charges for any selected optional services(See front).
1. If you want this receipt postmarked,stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at a post office service
window or hand it to your rural carrier(no extra charge).
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the a)
return address of the article,date,detach,and retain the receipt,and mail the article.
3. If you want a return receipt,write the certified mail number and your name End address
on a return receipt card,Form 3811,and attach it to the front of the article by n-eans of the
f gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article a
RETURN RECEIPT REQUESTED adjacent to the number. Q
4. If you want delivery restricted to the addressee, or to an authorized agent of the O
O
addressee,endorse RESTRICTED DELIVERY on the front of the article. M
5. Enter fees for the services requested in the appropriate spaces on the front of this
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811. , t€
6. Save this receipt and present it if you make an inquiry. t o2595-s7-B-ot 45 Cl)
zSENDER: I also wish to receive the
■Complete items 1 aind/or 2 for additional services.
as ■Comp)4;tie items 3,4a,and 4b." following services(for an
W OPrint
your
name and address on the reverse of this form so that we can return this extra fee):
card
■Attach this form to the front of the mailpieoe,or on the back if space does not 1. ❑ Addressee's Address
.. permit.
y •Write'Retum Receipt Requested'on the mail piece below the article number. 2. ❑ Restricted Delivery y
�. ■The Return Receipt will show to whom the article was delivered and the date ..
e. delivered. Consult postmaster for fee. SL
v 3.Article Addressed to: 4a.Article Number d
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LU and fee is paid)
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Ps Form 3811, Dt3cem r 1994 102595-97-B-0179 Domestic Return Receipt
UNITED STATES POSTAL SERVICE 1 FErst-Class MailPostage&.Fees PaW
USPS
Permit No.G-10
® Print your name, address, and ZIP Code in this box
Public Health Division
flown of Barnstable
P 0. Box 534
Hyannis,Massachusetts 02601
v.
BIKE Town of Barnstable
Department of Health, Safety, and Environmental Services
BAMffrMLE. = Public Health Division
y MASS.
163q. �0 s 367 Main Street,Hyannis MA 02601
pry�
Office: 508-790-6265 Thomas A. McKean,RS, CHO
FAX: 508-790-6304 Director of Public Health
January 6,1998
Teo Rajsombath
206 Bishops Terrace
Hyannis,MA
ORDER TO COMPLY WITH 310 CMR 15.00,THE STATE ENVIRONMENTAL CODE,
TITLE 5.
The septic system owned by you located at 206 Bishop's Terrace,Hyannis was inspected on December 12,
1997,by John Graci a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of 1995
TITLE 5 (310 CMR 15.00)due to the following:
• "The leaching pit was full. It was past the effective depth of leaching. The soil absorption
system was in hydraulic failure"
• Septic tank was not accessible-located underneath a deck.
You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram
of a proposed system to the Town of Barnstable Health Division Office(Town Hall, 367 Main Street,
Hyannis)that will bring the septic system into compliance with 310 CMR 15.00,The State Environmental
Code,Title 5 within(30)thirty days of receipt of this notice.
You are also directed to bring the septic system into compliance within sixty(60)days of receipt of this
order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic
system to prevent discharge of sewage or effluent into the buildings,onto the surface of the ground,or in
to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to any court of
competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A.McKean,R.S., C.H.O.
Agent of the Board of Health
q\health\dbfiles\title5 i.doc
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Dept. of Environmental Protection
One winter Street,Boston,Ma. 02108 John Septic
D.E.P. Title V Se Septic Inspector
P.O. Box 2119
Teaticket, MA 02536
WILLIAM F.WELD (508)564-6813
Governor
ARGEO PAUL CELLUCCI -
Lt.Governor
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM DEC' S 5 IS97
PART A
CERTIFICATION
Property Address: 206 BishoP4errace Hyannis Address of Owner:
Date of Inspection: 12/12/97 (If different)
Name of Inspector: John Graci Teo Rajsombath
I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000)
Company Name,Address and 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 sewage disposal systems. The system:
_ Passes This Inspection Is based on criteria defined In Title V
Conditional) Passes code 310CMR16303.My findings are of how the system is
y performing atthe time of the inspection.My inspection does
—Nee
dsEvaluation By the Local Approving Authority not Imply any warranty or guarantee of the iongevityofthe
X Fails septic system and any of its components useful life.
Inspector's Signature: Date: 12/12197
The System Inspector shalpy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C,or D:
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system,upon completion
of the replacement or repair,passes inspection.
Indicate yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
CoMpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank,whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 007197)
One Winter Street . Boston,Massachusetts 02108 a FAX(617)556-1049 • Telephone(617)292-5500
k ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 206 Bishop Terrace Hyannis
Owner: Teo Rajsombath
Date of Inspection:12/12197
Sewage backup or.breakout.or high.static water level observed.in.the distribution box is due to a broken,
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
—The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health;safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
— The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
— The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersupply well.
— The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
— The system has a septic tank and soil absorption system and 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 presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
D] SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
x I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure.
Yes No
-X— Backup of sewage in facility or system component due to an overloaded or clogged SAS or
cesspool.
x_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
x_ - • SAS-is in hydraulic failure.
(reylsed 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 206 Bishop Terrace Hyannis
Owner: Teo Rajsombath
Date of Inspection:12/12/97
D]SYSTEM FAILS(continued)
Yes No
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 112 day flow.
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
— Numbers of times pumped
x Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
—X• Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
x Any portion of a cesspool or privy is within a Zone 1 of a public well.
—X_ Any portion of a cesspool or privyis within 50 feet of a private water supply well.
x Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following:
The following criteria apply to large systems in addition to the criteria:
_ The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist:
Yes No
x the system is within 400 feet of a surface drinking water supply
x the system is within 200 feet of a tributary to a surface drinking water supply
_ x the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(reylsed 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 206 Bishop Terrace Hyannis
Owner: Teo Rajsombath
Date of Inspection:12112197
Check if the following have been done:YOU must indicate either"Yes"or"No"as to each of the following:
_c_ — Pumping information was requested of the owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
— — flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
— x As built plans have been obtained and examined. Note if they are not available with N/A.
x — The facility or dwelling was inspected for signs of sewage back-up.
x — The system does not receive non-sanitary or industrial waste flow.
—x— — The site was inspected for signs of breakout.
x All system components, excluding the Soil Absorption System, have been located on the site.
x The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected
for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on
The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information. Ex. Plan at B.O.H.
x Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is
— — unacceptable)[15.302(3)(b)]
(revised WNW)
I
k
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 206 Bishop Terrace Hyannis
Owner: Teo Rajsombath
Date of Inspection:12/12197
FLOW CONDITIONS
RESIDENTIAL:
Design flow: 220 g•p•d./bedroom for S.A.S.
Number of bedrooms: 2
Number of current residents: 6
Garbage grinder(yes or no): No
Laundry connected to system(yes or no): Yes
Seasonal use(yes or no): No
Water meter readings, if available:(last two(2)year usage(gpd):
rda
Sump Pump(yes or no): No
Last date of occupancy: n1a
COMMERCIAL/INDUSTRIAL:
Type of establishment: nia
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No
Water meter readings, if available: nra
Last date of occupancy: nta
OTHER:(Describe) nla
i
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
Na
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: nla
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no) ( if yes, attach previous inspection records, if any)
VA Technology etc. Copy of up to date contract?
Other:
APPROXIMATE AGE of all components, date installed(if known)and source information:
16 years
Sewage odors detected when arriving at the site: (yes or no) No
(revised 0427187)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 206 Bishop Terrace Hyannis
Owner: Teo Rajsombath
Date of Inspection:12/12197
SEPTIC TANK: x
(locate on site plan)
Depth below grade: rda
Material of construction:x concreate metal FRP Polyethylene—other(explain)
If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: rda
Sludge depth:n1a
Distance from top of sludge to bottom of outlet tee or baffle: ria
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance form bottom of scum to bottom of outlet tee or baffle:Wa
How dimensions were determined: rda
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage,etc.)
Septic tank was unaccessable,tank Is under deck.
GREASE TRAP:_
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions.
nla
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:rda
Distance from bottom of scum to bottom of outlet tee or baffle: rda
Date of last pumpingn,�,
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
rda
BUILDING SEWER:
(Locate on site plan)
Depth below grade: nra
Material of construction:_cast iron_40 PVC_other(explain)
Distance from private water supply well or suction Iine7va
Diameter: nia_
Qmments: (conditions of joints,venting,evidence of leakage, etc.)
(revised 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 205 Bishop Terrace Hyannis
Owner: Teo Rajsombath
Date of Inspection:12I72l97
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: rda
Material of construction:_concrete_metal_FRP_Polyethylene—other(explain)
Dimensions: nia
Capacity: rda gallons
Design flow: r1a gallons/day
Alarm level:_nra Alarm in working order?_Yes_No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
rda
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert: n1a
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
rda
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(yes or no)No
Alarms in working order(yes or no)_Yes
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
rda
(revised 04127)97)
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 206 Bishop Terrace Hyannis
Owner: Teo Rajsombath
Date of Inspection:12112197
SOIL ABSORPTION SYSTEM (SAS):x
(locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods)
If not determined to be present,explain:
rda
Type:
leaching pits,number: 1,=gallon leach pft
leaching chambers, number:rva
leaching galleries, number: nla
leaching trenches, number,length: rda
leaching fields, number, dimensions:r9a
overflow cesspool,number:nia
Alternate system: rda Name of Technology:_wa
Comments: (note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
The leach field Is peat the effeedve depth of leaching.The sea Is In hydraulic rallure.Pitwas full.
CESSPOOLS:
(locate on site plan)
Number and configuration: Na
Depth-top of liquid to inlet invert: rda
Depth of solids layer: nfa
Depth of scum layer: nla
Dimensions of cesspool: rda
Materials of construction: rda
Indication of groundwater: nfa
inflow(cesspool must be pumped as part of inspection)
nfa
Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
nfa
PRIVY:
(locate on site plan)
Materials of construction: nla Dimensions: Na
Depth of solids: nra
Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
rda
(reylsed 04127)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
206 Bishop Terrace Hyannis
Teo Rajsombath
12112197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references, landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
Via P I"
3
Page ! of 20
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
206 Bishop Terrace Hyannis
Teo Rajsomdath
12/12197
Depth of groundwater 12
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property, observation hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
(revised04r27197) Page 10 of 10
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Sewer Information
" 12/16/97
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IN John Grad
12/12/97
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'
M ,. OW1 1/20/98 m ` Installer
` 3/20/98
W/1 4a LPT'1,4 ON
p��
Town of Barnstable
Department of Health, Safety, and Environmental Services
Public Health Division
MAM
a A�� 367 Main Street,Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
January 6i 1998
Teo RaJso mbath
206 Bishops Terrace
Hyannis,MA
ORDER TO COMPLY WITH 310 CMR 15.00,THE STATE ENVIRONMENTAL CODE,
TITLE 5.
The septic system owned by you located at 206 Bishop's Terrace,Hyannis was inspected on December 12,
1997,by John Graci a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the guidelines of 1995
TITLE 5 (310 CMR 15.00)due to the following:
• ��The leaching pit was full. It was past the effective depth of leaching. The soil absorption
system was in hydraulic failure"
• Septic tank was not accessible-located underneath a deck.
You are directed to hire a licensed Town of Barnstable septic system installer to submit a sketch diagram
of a proposed system to the Town of Barnstable Health Division Office(Town Hall, 367 Main Street,
Hyannis)that will bring the septic system into compliance with 310 CMR 15.00,The State Environmental
Code,Title 5 within(30)thirty days of receipt of this notice.
You are also directed to bring the septic system into compliance within sixty(60)days of receipt of this
order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to pump the septic
system to prevent discharge of sewage or effluent into the buildings,onto the surface of the ground,or in
to surface waters.
I
Any person aggrieved by any order issued by the local approval authority may appeal to any court of
competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
(t�
omas A.McKean,R.S., C.H.O.
Agent of the Board of Health
q\health\dbfiles\title5i.doc
[Installer letter]
TO: leO (Date)
,s Tecrc,-c e-
d►k
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at /�+ � vVas►
inspected on C8e. 124/`ri7 by c; a Massachus tts licensed septic
inspector.
The inspection of your septic system showed that your system has failed under the
ide' s of 1995 TITLE 5 (310 CMR 15.00) due to the following:
to l.C�icE, ,� wcb 3t woS eveUeWp o
ou are directed to hire a licensed Town of Barnstable septic system insta er to submit a
sketch diagram of a proposed system to the Town of Barnstable Health Division Office ��^
(Town.Hall, 367 main Street, Hyannis) that will bring the septic system into compliance ����,c
with 310 CMR 15.00, The State Environmental Code, Title 5 withinaen days of �,�,{
receipt of this notice. *fly rs
You are also directed to bring the septic system into compliance within t1 3A days of
receipt of this order letter.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
No..2,2Y.......... FimicctP..........
THE COMMONWEALTH OF MASSACHUSETTS
B®AR F HEALT
Applirativia for Disposal Works Tunstrurtion runtit
Application is hereby made for a Permit to Construct ( ) or Repair ( " ) an Individual Sewage Disposal
?6� Sy at
h v i A�IZG� l� d
............... n........._•---.:.--.----..... ��� .f ................. �._....�.-----•--......................._...----..............
...... . Loca ott Address �.............. ................ ..... or Lot.No............................ ... .......
Owner ,....Address
............- ...!�.hJ,f�.. .':+�. .. .G..f.................... ...................................... .....................---...........................
Installer Address , ..
Q Type of Building Size Lot._LUi....
.. feet
U Dwelling—No.. of Bedrooms....... ...........................Expansion Attic ( ) Garbage Grinder ( }
04 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a Other tures --------------------------------- .
W
Design Flow......... 0........................gallons per person per day. Total daily flow....___...._... .o........._.......gallons.
WSeptic Tank—Liquid capacity/0 C1 Qgallons Length................ Width................ Diameter.... Depth................
Disposal Trench—No..................... Width.................... 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 ( )
aPercolation Test Results Performed bY........................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water-_____-_____-__-___-_-_.
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
O -.............................t.............-•-•----------..._......................••••--------•-----............_•-••-...----••----
Description of Soil-------- -- ------ -- -----C lL-/ -Ll ......---------•----......._..----•-----------------
U ------------------------------------------•-----•---...-----._.._...........------.----•--•------••-••-••--•--•-•••--••------•---•----••--------•--------•-•-••-•-•---•-•---•----••............•--•-••--
W
-----------------------------------------------------------•--------------•-----------------...-•--------•-----------------.....------.....------ ---------------------------------------•---------•--
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
---------------------------------------------------------------------------- ---------••-....._.....-•------•----------•-------------•--••-----•-•-----••----------------••---•-•----•-•-----------•....
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code; The undersigned further agrees not to place the system in
operation.until a Certificate of Compliance has n issued by the
boar44 healt . / f
Signe . .C� � ..� .....................
: -•-?p-Ta.G:-.7_L.
Application Approved BY =`' ° �� - ���..--------- -•-•. /_ t�:�.a'`L
Application Disapproved fo the following reasons________________________________ _
------ ------•.................................. Date---...........
•--•-•-•-------------------------------------------------------------------------------------------•--------•-•---••--•--------•--•---••••-----•-•••----...-•--•--••-----•-••......------••---._._.....
Date
7
Permit No......�.��----------•::.......................... Issued........ -----�.�-�--•--
? Date
----- - ----------- -- ------
r ^�
k Yrt'✓
y ,",in+.fipdr
THE COMMONWEALTH OF MASSACHUSETTS
BOARD ®F HEALTH
t,> ..... ......... oF........fr ,�F.. .. �...r............------
Appliratintt for 43hynsal Warks Tntnstrurtinn umit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
I
..... ,.11-.....:.. N
Location Address J 4/0r Lot No...........................................
.... ?4•�yj :...c ` «�................ ...•..,..,.................................. ...........................................
wn`er Address
........... :. i,.J;.� �ta:.d� . .{.�,:.�.. t.. .(:................•... .•........•......................................................................................
Ins`ialler Address
U Type of Building Size Lot.. "_.--_..� S feet
Z � q
a Other g Type of Building ............................ N Expansion Attic ( ) Garage Grinder ( )
Dwelling—No.No. of Bedrooms........ .........................
._..... o. of persons............................ Showers ( ) — Cafeteria ( )
Other fixtures ...............
W Design Flow.......... ........................gallons per person per day. Total daily flow................ '°. .. ...........gallons.
P4 Septic Tank—Liquid capacity i' �;_..gallons Length................ Width................ Diameter----& ,--- Depth................
x Disposal Trench—No.............:....... �idth....._.............. 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 ( )
H Percolation Test Results Performed bv.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water---_______--___.-_-.-__.
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
1:4 ...•"--••-••-'--'•---•••...-•-•-••••••••................•----•••-.........•••-"'-••-••-••-•..---'-.........................................................
ODescription of Soil........ ..... ... ........•------'••-••---'--•---'---•---•----------•--•-----------•--'-'-•-----------'----'----•------'-
V .....••-••-••••-•........................................................
W
•------•-•••.................................................••-----.....---'•-••---'-'•--..._......................... •-----•-'........--'---••-•'•-•--..............--••-.........__......_..........
V Nature of Repairs or Alterations—Answer when applicable................................................................................................
..........................-.............................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has J11en issued by the board of health.
Signe ...... �i�
Application Approved By :_ '" ' e f
>...... N
v.,e.....-.
Hate
Application Disapproved for•,the following reasons:................................. ..
-------------•-"-------------••------------•--••••-•--••...............
-----.......•....---••-------------•----------------'----'•••-•......----•••'•'......•--.......-••••••........---"-'--•-•-•-•"•--'•-----...---••--•-••'---'--•-•••'--....•-•••-••---•-•-•......--•.....
Date
Permit No....... .. c/ ..... Issued--.......
................................ _.•-- •- ---------- -------.----
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH fJ
`6 :`,.0 n...................0F........
Taft,filratr Jai &MAitnrr
THY IS TO ERTIV,`Y, Th .the Individual Sewage Disposal System constructed ( ) or Repairedby. ( )
..................as - -------------------------------------------------------------------------------------------------
a talc
•� djJ// y �"
at_ /i--.._
.......... � f%J ��j � rtr! ! 'i t�E�-------------•--------•----•----
has been installed in accordance with the prcr�,ions�f t\rticle XI of The Str Sanitary Code as described in the
application for Disposal Works Construction Permit No......................................... dated...._-_._.____.I......_121(i__....74n.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................•--------....---•------•-...........................•••--_..... Inspector = '1 .. .!,f�'! e' ,r3. '.r.... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
{ ,r .. i............OF. r" " ry.af ........................ FEE..* :.�
No �'
3�i n 1 f rk,i Ton trurti n prntit
Permission i "hereby granted ..........-••..........................................
at No.. ...�.. .....:..� .... ` .� �- - f -- -�l isposal System to Constr ft ) or Repair, ) ai Individual Sewe
/- v
sF'• :.. ':rg> .Ap6I�' . ... .! .{.•AFs"'�.r...rw,............
..........................
* ! Street
as shown on the application for Disposal Works Construction P n t No.__ !" .„� atecl....::-fi r�., z
,.. !r, E '' '1r¢ `•r f �... ......................»
Board of HealtL
DATE---••......................................................,::__.
`, FORM 1255 HOBBS & WARREN, INC.. PURL ISHER$ -