HomeMy WebLinkAbout0335 BISHOPS TERRACE - Health 335 Bishops Terrace
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TOWN OF BARNSTABLE
LOCATION A;A� Y 791)r,�`e- SEWAGE #
VILLAGE ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY AVd
LEACHING FACILITY: (type)o�-�1�7 / (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: 7��`�� COMPLIANCE DATE: v
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any well ds exist
within 300 eet of le 'n.�a�� � Feet
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TOWN OF BARNSTABLE
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`17ILLAGE ASSESSOR'S MAP & LOT
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'S NAME & PHONE NO. A & B CANW 775-6264
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER -U-,4 N
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: C '�''
` VARIANCE GRANTED: Yes No
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INSTALLER'S NAME&PHONE NO. g C6,rt(0
SEPTIC TANK CAPACITY
�.. LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
, �n v� G��e 4,C— ��6
BUILDER OR OWNER //
PERMIT DATE: h Zo t COMPLIANCE DATE: s
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
_tf on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
t within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts
. Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
335 Bishops Terrace
Property Address
Madalena and Olinda Tatara
Owner Owner's Name
information is September 15, 2008 Hyannis MA 02601 Se
required for H_ Y p
every 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.
Important:When filling out A. General Information
e,
forms on the
computer,use 1. Inspector:
only the tab key
to move your David D. Cou hanowr '
cursor-do not use the return Name of Inspector
key. Eco-Tech Environmental -b
Company Name
43 Triangle Circle : bo
Company Address fV
Sandwich MA 663
City/Town State 4p Code
508 364-0894 1328
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
L �Pe -� iLS September 15, 2008
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 th future under
the same or different conditions of use.
t5-3031.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
335 Bishops Terrace
Property Address
Madalena and Olinda Tatara
Owner Owner's Name
information is Hyannis MA 02601 September 15, 2008
required for H y p
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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:
Inspector's Note==> A septic system is deemed to pass this Real Estate Transfer Inspection if it
does not trigger any of the failure criteria listed below. The septic system has been evaluated
according to the conditions observed on the day it was inspected. No estimate or guarantee of
system longevity is made or implied by a passing determination.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
t5-3031.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
335 Bishops Terrace
Property Address
Madalena and Olinda Tatara
Owner Owner's Name
information is H September 15, 2008 annis MA 02601
required for Y
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
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 P P Y
❑ 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 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.
15-3031.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 335 Bishops Terrace
Property Address
Madalena and Olinda Tatara
Owner Owner's Name
information is Hyannis MA 02601 September 15, 2008
required for Y p
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
Liquid depth in cesspool is less than 6" below invert or available volume is less
❑ ® than %day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
t5-3031.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
335 Bishops Terrace
Property Address
Madalena and Olinda Tatara
Owner Owner's Name
information is September 15, 2008 Hyannis MA 02601 Se
required for H Y p
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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-
i El ® 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.
I
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.
t5-3031.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
335 Bishops Terrace
Property Address
Madalena and Ci inda Tatara
Owner Owner's Name
information is Hyannis MA 02601 September 15, 2008
required for Y p
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate "yes" or"no" as to eac� 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? (I-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?
2 leach pits
inspected in lieu ❑ ® Were all system components, excluding the SAS, located on site?
of d-box.
Outlet end only. ® ❑ Were the septic tank manholes uncovered, opened, and the i iterior 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)]
t5-3031.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage D sposal System•Page 6 of 15
Commonwealth of Massachusetts
w W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
335 Bishops Terrace
Property Address
Madalena and Olinda Tatara
Owner Owner's Name
information is September 15, 2008 Hyannis MA 02601 Se
required for H Y p
every page. CityTTown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): n1a Number of bedrooms (actual): 3 per assessing
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): n/a—no plan
Number of current residents: 5
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage d 313 gpd
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: currentDate
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
1 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:
Last date of occupancy/use: Date
Other(describe):
t5-3031.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
335 Bishops Terrace
Property Address
Madalena and Olinda Tatara
Owner Owner's Name
information is H annis MA 02601 September 15, 2008
required for Y p
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: Owner
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
p P Y
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
Age unknown—system is assumed to have been installed at time of dwelling's construction in 1972
and may have been repaired or upgraded at a later date
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5-3031.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 335 Bishops Terrace
Property Address
Madalena and Olinda Tatara
Owner Owner's Name
information is H rinis MA 02601 September 15
required for Y p , 2008
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2
feet
Material of construction:
i
❑ 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.):
No evidence of leakage or backup into dwelling was observed.
Septic Tank(locate on site plan):
Depth below grade: 1
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: undetermined
Sludge depth: 6 in
Distance from top of sludge to bottom of outlet tee or baffle 28 in
Scum thickness 4 in
Distance from top of scum to top of outlet tee or baffle 6 in
Distance from bottom of scum to bottom of outlet tee or baffle 12 in
How were dimensions determined?
t5-3031.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 335 Bishops Terrace
Property Address
Madalena and Olinda Tatara -
Owner Owner's Name
information is Hyannis MA 02601 September 15, 2008
required for y p
every 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.):
Pumping is recommended within one year and maintenance pumping is recommended every two
years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage
in or out was observed. Tank is under deck with trap door and cast iron cover to grade at outlet end.
Inlet end not accessible.
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 scu n to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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):
t5-3031.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
'wM 335 Bishops Terrace
Property Address
Madalena and Olinda Tatara
Owner Owner's Name
information is H September 15, 2008 annis MA 02601
required for y
every page. City/Town State Zip Code Date of Inspection
II
i
D. System Information (cont.)
Tight or Holding Tank(cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box is under finished deck with no access provided. System has instead been evaluated according
to the condition of the leach pits which were uncovered(see page 12)
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5-3031.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
335 Bishops Terrace
M
Property Address
Madalena and Olinda Tatara
Owner Owner's Name
information is Hyannis MA 02601 September 15, 2008
required for y p
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System SAS locate on site Ian excavation not required):
p Y ( ) ( p
If SAS not located, explain why:
Type:
® leaching pits number:
2
❑ leaching chambers number:
❑ 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.):
Soils above leaching pits appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. Leach pit 1 was full to within 8 inches
of the inlet invert. Effluent was observed in Leach pit 2 at three feet below the inlet invert. Staining
was observed 2 feet below invert. Cover and interface were clean.
t5-3031.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
335 Bishops Terrace
Property Address
Madalena and Olinda Tatara
Owner Owner's Name
information is H September 15, 2008 annis MA 02601
required for Y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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.):
t5-3031.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
335 Bishops Terrace
Property Address
Madalena and Olinda Tatara
Owner Owner's Name
information is Hyannis MA 02601 Se tember 15, 2008
required for Y p
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties
to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
LEACH LEACH
PIT PIT
• t
2
D-80X o SEPTIC
0
TANK
DECK
A EXISTING 8 LOCATIONS
DWELLING A B
# 335 1 51 FL 32 FL
2 21 FL 61 FL
Z
J
Q!
W
F-
6
3I
BISHOPS TERRACE NOT TO SCALE
t5-3031.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 335 Bishops Terrace
Property Address
Madalena and Olinda Tatara
Owner Owner's Name
information is September 15, 2008 Hyannis MA 02601 Se
required for H y p
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to ground water: 20+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:
Barnstable GIS Department records
You must describe how you established the high ground water elevation:
Town of Barnstable GIS Department records indicate that the property is over 20 feet above
groundwater table.
15-3031.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
All
v
No... Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _✓
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Yes
Zfpprtcatfon for Migool 6pgtem Construction Permit
Application for a Permit to Construct( . )Repair P<Pgrade( )Abandon( ) O Complete System C rtdividual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
3 3 S- 461$7110,45 Tt,e �s✓ 7 ,4 NL S 1rI C li.,i e z
Assessor's Map/Parcel 3
Installe 's Name,Address,and Tel.No. -�U s-a'��D Designer's Name,Address and Tel.No.
CPA NC0 3S® /h/-Y//v )r
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 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
Nature of Repairs or Alterations(Answer when applicable) f P C r-
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been isspqby this Board of Health.
S �y
Signed Date
-�
Application Approved by Date
Application Disapproved for the following reasons
Permit No. Date Issued
r_
y:
I`G _ t/► Fee
r y Entered in computer: V
THE COMMONWEALTH OF MASSACHUSETTS
Yes
PUBLIC HEALTH DIVISION - TOWWOF BARNSTABLE., MASSACHUSETTS
2pplication for nigpogat *pgtem Construction Permit
Application for a Permit to Construct( )Repair( h4upgrade( )Abandon( ) O Complete System LJ'Tndividual Components
Location Address or Lot No. Owner's Name,Address and Tel.No.
3 3 SS 181511010E '7—,4 A S I £4c,/c -z
Assessor's Map/Parcel i j,-r-- / — / / u 3 3 5 IJ1 ,S'/ a,,—S
Install e's Name,Address,and Tel.No. So 8 c® Designer's Name,Address and Tel.No.
J-13 (a/9 Al C O 3 5 0 ST
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(: )
Other TI pe 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,
d
Nature of Repairs or Alterations(Answer when applicable) f '� 4 C' £ ) 1_9 0-Y
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 issyeq by this Board of Health.
Signed OC1:1` �, _ Date
Application Approved by _ Gi i� � / D j f.!! �y9� � /r�� Date ��� I��'
Application Disapproved for the following reasons /
0r
Permit No. � Date Issued 19
THE COMMONWEALTH OF MASSACHUSETTS
ow/ BARNSTABLE, MASSACHUSETTS.
Certificate of Compliance
THIS IS TO CE TIFY that the On-site Sewage Disposal System Constructed( )Repaired( 4-TUpgraded( )
Abandoned( 1 by 0,4/� � C 5 ° �//�i/L 5
at 3 5 / S 116'0 5 T,,P y '/ , /has bee constructed in accordance
with the pro vis'ors of Title 5 and the for D' posal System Construction Permit No. dated
Installer Designer
The issuance of this`permit shall not be construed as a guarantee that the system ill�+ ction as esigne4
Date ri I u �. Inspector1� �1
1 �
No. (J�"I r / 4 d------------------------Fee �����•���
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Migogaf *pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( )
System located at 3 3 3-
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
''< �
Provided:Construction musYbe comple ed within three years of the date of this permit,
Date: f�/r /(� Approved by
TOWN OF BARNSTABLEL
LOC/nON '3 35 R(Sinn D I -�erAce SEWAGE # 2&J
VILLAGE 4VMOYII% ASSESSOR'S MAP & LOT oCS -
INSTALLER'S NAME&PHONE NO. &I 6r,rtC0
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type), (size)
NO.OF BEDROOMS
BUILDER OR OWNER un US k�f w, -Z
PERMTTDATE: G f COMPLIANCE DATE: (f
Separation Distance Between the:
Maximum Adjusted Groundwate able to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leashing facility) Feet
ge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
r:
r
3bq-7S
� P
COMMONWEALTH OF MASSACHUSETTS
Z w EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
a
+ d DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
�1M s�av
/� 350 MAIN STREET
/r"� WEST YARMOUTH,MA MAY 2 5 2004
508-775-2800
TOWN OF BARNSTABLE
TITLE 5 HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A r
CERTIFICATION MAP
MAP 251 PAR 178 PARCELProperty Address: 335 BISHOPS TERRACE
HYANNIS,MA 02601OT O
Owner's Name: JANUSZKIE,MARY JANE
Owner's Address: 335 BISHOPS TERRACE
HYANNIS,MA 02601
Date of Inspection MAY 7,2004
Name of Inspector:(please print) JAMES D. SEARS
Company Name: A&B Canco
Mailing Address: 350 Main Street
West Yannouth,MA 02673
Telephone Number: 508-775-2800
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the infonnation 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. 1 am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
J Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails .
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 tot he buyer,if applicable,and the approving authority.
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 1
i
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 335 BISHOPS TERRACE
HYANNIS,MA 02601
Owner: JANUSZKIE,MARY JANE
Date of Inspection: MAY 7,2004
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 CM 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes: N/A
One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.
The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined"
please explain.
The septic tank is metal and over 20 years old or the septic tank(whether metal or not)is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing
tank is replaced with complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval
of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if(with approval of the Board of Health)"
broken pipe(s)are replaced
obstruction is removed
ND explain:
Title 5 Inspection Form 6/15/2000 2
Page 3 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 335 BISHOPS TERRACE
HYANNIS,MA 02601
Owner: JANUSZKIE,MARY JANE
Date of Inspection: MAY 7,2004
C. Further Evaluation is Required by the Board of Health: N/A
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 salt marsh
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 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 detenmine distance
**This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility
and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided
that no other failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 335 BISHOPS TERRACE
HYANNIS,MA 02601
Owner: JANUSZKIE,MARY JANE
Date of Inspection: MAY 7,2004
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
i
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 pits is less than 6"below invert or available volume is less than''/z day flow
✓ Required pumping more than 4 tunes 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
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
it N/A Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. (This system passes if the well water
analysis performed at a DEP certified laboratory,for coliform bacteria and volatile organic
compounds indicates that the well is free from pollution from that facility and the presence of
ammonia nitrogen and nitrate nitrogen is equal or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. 1 have detennined that one or more of the above failure criteria exist as
described in 310 CM R 15.303,therefore the system fails. The system owner should contact
the Board of Health to detennine what will be necessary to correct the failure.
E. Systems:Large m S s. N/A
Y
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
You must indicate either"yes"or"no to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
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 is 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.
Title 5 Inspection Form 6/15/2000 4
1
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 335 BISHOPS TERRACE
HYANNIS,MA 02601
Owner: JANUSZKIE,MARY JANE
Date of Inspection: MAY 7,2004
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 nonnal 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?
a
✓ 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)has been determined based on:
Yes No
✓ Existing information. For example,a plan at the Board of Health.
✓ Detennined in the field(if any of the failure criteria related to Part C is at issue approximation of
distance is unacceptable)[310 CMR 15.302(3)(b)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 335 BISHOPS TERRACE
HYANNIS,MA 02601
Owner: JANUSZKIE,MARY JANE
Date of Inspection: MAY 7,2004
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: 2
Does residence have a garbage grinder(yes or no): YES
Is laundry on a separate sewage system(yes or no): . NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): N/A
Sump pump(yes or no) NO
Last date of occupancy: PRESENT
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CM 15.203):
Basis of design flow(seats/persons/sqft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): 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)
Tight tank Attach copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
UNKNOWN
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 335 BISHOPS TERRACE
HYANNIS,MA 02601
Owner: JANUSZKIE,MARY JANE
Date of Inspection: MAY 7,2004
BUILDING SEWER(locate on site plan): ✓
fDepth below grade:
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): ✓
Depth below grade:
Material of construction: ✓ concrete metal fiberglass polyethylene
other(explain)
If tank is metal list age: Is age confinned by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 28"
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 181,
How were dimensions detennined: ASBUILT AND 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.):
MAIN TANK AT WORKING LEVEL.OUTLET TEE.NO SIGN OF OVERLOADING OR LEAKAGE.
GREASE TRAP(located on site plan) N/A
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
Page 8 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
1 Property Address: 335 BISHOPS TERRACE
HYANNIS,MA 02601
Owner: JANUSZKIE,MARY JANE
Date of Inspection: MAY 7,2004
TIGHT or HOLDING TANK: N/A (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/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
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.,):
DISTRIBUTION BOX IS NEW MAY 2004.BOX IS 16"x16:", 10"BELOW GRADE.ONE LINE IN,TWO LINES
OUT.
PUMP CHAMBER: N/A (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no):
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Title 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 335 BISHOPS TERRACE
HYANNIS,MA 02601
Owner: JANUSZKIE,MARY JANE
Date of Inspection: MAY 7,2004
SOIL ABSORPTION SYSTEM(SAS): ./ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 2
leaching chambers,number:
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 TWO 1,000 GALLON PRE CAST PITS.PITS ARE 14"BELOW GRADE.20"WATER,STAIN
LINE AT 30".NO SIGN OF OVERLOADING OR SOLID CARRYOVER.
CESSPOOLS: N/A (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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
Page 10 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 335 BISHOPS TERRACE
HYANNIS,MA 02601
Owner: JANUSZKIE,MARY JANE
Date of Inspection: MAY 7,2004
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two pernianent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
A.
i
r✓ �/
y,.
Title 5 Inspection Form 6/15/2000 10
Page I I of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Propertp Address: 335 BISHOPS TERRACE
HYANNIS,MA 02601
Owner: JANUSZKIE,MARY JANE
Date of Inspection: MAY 7,2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to no groundwater 10 feet
Please indicate(check)all methods used to detennine the high ground water elevation:
Obtained from systein design plans on record-If checked,date of design plan reviewed:
./ Observation 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:
HAND DUG TEST HOLE 10'NO WATER. TEST HOLE Y BELOW BOTTOM OF PIT.
I
i
s
Title 5 Inspection Form 6/15/2000 11
I r
w TOWN OF BARNSTABLE
LOCATION 3.5 Lg cgf SEWAGE # - 3
•VILLAGE ^S ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. ��f� G ��� ��/'-rs� l 1 c
`SEPTIC TANK CAPACITY
;LEACHING FACILITY:(type) °� (size) 1-8ig
NO.. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER CAX4,k
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
l
O
i / N Cli
i
i
No..f&3_U
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
1�
Appliratiou for Disposal Works Toustrurtiun remit
Application is hereby made for a Permit to Construct ( ) or Repair �X) an Individual Sewage Disposal
System at:
335 Bishops Terrace Hyannis,Mass .
................ ........_.......... • ......•••................. ...............................:..................................................................
C a to ld o Location-Address or Lot No.
..........-...........—.......................................................................... ..................c.....................................................•.........................
W
J.P.Macomber J r. owner Address
Pq Installer Address
d Type of Building Size Lot............................Sq. feet
V Dwelling x No. of Bedrooms.............. .--......Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
C4 Other fixtures -----------------•-------------•---•-----------•------
W
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity......--....gallons Length................ Width................ Diameter................ Depth................
x 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 ( )
Percolation Test Results Performed by..............-........................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit................--.. Depth to ground water........-----...........
GZ4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water...---..................
9 --------------------------•---------------•----...-------------------••••••---•----•---------• ------
---....--•----------------------------...
0 Description of Soil------.... ---------•---------------------------•----•------------------•--------------•--•---•.................
W Sand & Gravel ..... ........•••----------•--------
W
U Nature of Repairs or Alterations—Answer when applicable................................................................................._..............
-•---------------------------------------------1-1000 gallon--- i t
---------------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the
system in operation until a Certificate of Complia ce has b en • sued by the bo d of he th.
Signed ..---- � 8/2�/90
Dace
Application Approved By --------------- ---...... - ---� - '...-..0
Application Disapproved for the following reasons- ------------- --------------------------------------------------------------------------------------------- ------------
....... Dace
-------------- —... .....................,....-'--- --------------..........._....--.-.................... .... ....'------------- '--.-- .............. Dace
PermitNo. �-------.3-..� � ....---- Issued -------------------------------- ......................
• �'
ND....l-. __�— Fs$.. ... O.,�J_
\/U THE COMMONWEALTH OF MASSACHUSETTS 1
i\ BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Disposal Works Tonutrurtiurt Prrmit
Application is hereby made for a Permit to Construct ( ) orr Repair (XX) an Individual Sewage Disposal
System at:
335 Bishops Terrace Hyannis,Mass.
...- -- ••-•-•-•---••- ----- - ._... - -----------------------------------------•-----._...._...------•---=---•._.._.......---•-------
Cato ldo Location:Address or Lot No.
......................_ _ -... - - .............................................. ...................................................-•--...................................------
W J.P.Macomber Jr. Owner Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelli -�'No. of Bedrooms_______________-t_________________._-_---._Ex Expansion Attic
a ng p ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures --------------------------------------------------•----------------------------------------------------------------------....-----------.._..--------
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'ca.pacity_-___--_____ga.11ons Length................ Width................ Diameter................ Depth................
x 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 ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I________________minutes per inch Depth of Test Pit.................... Depth to ground water........................
fX4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water----___--------___------
01 -.....
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•------------------------------------------••-•----------•----_-----
0 Description of Soil..............................................................................=----------------------------•--------...._......_....---•-----------------••----•-------
U ....--•--------------------------------•--Sand..&--Gravel----------••------------•-------•-------------------------------------._....------------•----------••----•-•------------
W
UNature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
------------------------------------------------1--1..JO--�................. P. t..------....-----------------------....
Agreement:
The undersigned agrees to install the aforedescribed Ind'ividual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental Code'-The undersigned further agrees not to place the
system in operation until a Certificate of Complian a has b en issued by the boa d of he th.
8/28/90
Signed . .. ........... --....------ ------------------..te.................
♦y. Dare
Application Approved By ----- - .C.��- ..,-•---,..... ------------------ '----..r.0
Application Disapproved for the following reasons- --------------------------------------------------------------------------------------------------------------------------------------
.......------.............................................................................................................................................................................................---.. ................Date------....--------
" Permit No. ----- 0�....----- ..................... Issued --------------------------------------------------------- ------
Date
THE-COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(fertifi> ate of Tomplianre
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XX )
by _---_--_-_J P.Macomber Jr.
.........................- -- - ----------------------------------------- ---------------------- ................-----------------------------------------------------------------------------------------------
at
335 Bishops Terrace Hyannis Insmller
---------------------.........................................................................................-------------------------------------------------------------------------------------------------------------
� ,,,F has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ...........5.��......3.8 .... dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE------------------- Inspector ��Z- ---------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�y c� TOWN OF BARNSTABLE
No._..(Q._`_..3_�I� FEE....$...3�..00
Disposal Works Tunutrurtiun rrrmit
Permission is hereby granted-_.J.-P.Macomber !Ir.............................................................•-_-_.....
to Construct ( ) or Repair (XX) an Individual Sewage Disposal System
at No._. 35__Bishops-Terrace•_Hyannis..............•------------...------------------•----•---.................._....._....--------....----•...-••-
Street qq
as shown on the application for Disposal Works Construction Permit No._/_\\_�" _? Dated..........................................
T�t---- ------------
DATE..................?-=-2-a_-.��.�...................................
Board of Health
FORM 36508 HOBBS h WARREN.INC..PUBLISHERS