HomeMy WebLinkAbout0047 BISHOPS TERRACE - Health 47 Bishops Terrace,Hyannis
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TOWN OF BARNSTABLE
LOCATION y 7 �i 5 orJ3 r��rv��ci- SEWAGE # 7, GG 1
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. as epl Le- /3ar.»,0 j
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SEPTIC TANK CAPACITY /606
LEACHING FACILITY: (type) 2-3-,90 6.wl (size) _ZS—A /3'?
NO.OF BEDROOMS 3 ,,�
BUILDER OR OWNER eoll 4-3 e�, A
PERMITDATE: I1—/7-47 COMPLIANCE DATE:
Separation Distance Between the: t
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching faci 'ty) .� Feet
Furnished by .a
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Commonwealth of Massachusetts °�51' a 0(a
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,j
,u 47 Bishops Terrace
Property Address �.
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Na
information is Hyannis
required for every r MA 02601 10-04-2019:-,
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling t forms
A. Inspector Information
ou
on the computer,
use only the tab Michael T Bisienere
key to move your Name of Inspector
cursor-do not Cape Septic Inspections
use the return Company Name
key.
52 Rivers End Road
� Company Address
Teaticket Ma. 02536
City/Town State Zip Code
r 508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above; the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection.was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ® Passes
2. ❑ Conditionally Passes
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
10-05-2019
Inspector's Signature Date -----------
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: This report only describes conditions at the time of inspection and under the
conditions of use at that time. This inspection does not address how the system will perform
in the future under the same or different conditions of use.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Bishops Terrace
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6.
1) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
This 3 bedroom home has a H-10 1000 gallon septic tank and a H-10 D-Box feeding two 500 gallon
leaching chambers.At the time of the inspection there was appx. 8 inches of ponding water and there
were no visible failure criteria found.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
Commonwealth of Massachusetts
p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Bishops Terrace
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
-
page. Cityrrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes (cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
3) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
a. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Bishops Terrace
� p
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
❑ ® 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
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Bishops Terrace
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ ® 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 '/2 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.
El Z 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 water supply
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 2000 gpd-
10,000 gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
5) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section CA.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Flo Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Bishops Terrace
Property Address
` PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
page. Cityfrown State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered "yes" to any question in Section C.5 the system is considered a significant
threat, or answered "yes"to any question in Section CA above the large system has failed. The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner
should contact the appropriate regional office of the Department.
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Bishops Terrace
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
page. Cityfrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 plus
GPD
Description:
Number of current residents: 7
Does residence have a garbage grinder? ❑ Yes ® No
Does residence have a water treatment unit? ❑ Yes ® No
If yes, discharges to:
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage (gpd)):
Detail
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Bishops Terrace
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. 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
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes '❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Bishops Terrace
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
a new leaching was installed in 1997
Were sewage odors detected when arriving at the site? ❑ Yes ® No
5. Building Sewer(locate on site plan):
Depth below grade: 19"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: Town water
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
water was flushed and it came freely.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
�l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Bishops Terrace
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 12"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:
standard H-10 1000 gallon
Sludge depth: 3"
Distance from top of sludge to bottom of outlet tee or baffle
33"
Scum thickness
V
4"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
13"
How were dimensions determined?
sludge judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I recommend the new owner have the tank pumped and then put the septic tank on a maint. plan with
a local septic pumping co. based on the future use of the home. At the time of inspection the liquid
level was at working level and the tee's were in place.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
1 Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Bishops Terrace
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
I
I
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
V 47 Bishops Terrace
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owners Name
information is required for every Hyannis MA 02601. 10-04-2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
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.):
At the time of the inspection the liquid level was at working level and there were no visible signs of
leakage or solids carryover.
t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
' I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
i%
47 Bishops Terrace
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
® leaching chambers number: ( 2 ) 500 gallon
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Bishops Terrace
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS) (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
At the time of the inspection there was appx. 8 inches of ponding water and there were no visible
failure criteria was found.
12. 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.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Bishops Terrace
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
V 47 Bishops Terrace
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
14. 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
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t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- -
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
.., 47 Bishops Terrace
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 12 plus feetfeet
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:
augered a hole to 12 feet to show 4 plus feet of seperation.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Bishops Terrace
v -
Property Address
PEREIRA, DABSON CRISTIAN HERMOGENES
Owner Owner's Name
information is required for every Hyannis MA 02601 10-04-2019
i
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
® A. Inspector Information: Complete all fields in this section.
® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked
® C. Inspection Summary:
1, 2, 3, or 5 completed as appropriate
4 (Failure Criteria) and 6 (Checklist) completed
® D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18
a
Date:
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS REGISTRATION FORM
NAME OF BUSINESS: w-i C 2 J C A�J PA, I -IJ
BUSINESS LOCATION: 6 15 h o INVENTORY
MAILING ADDRESS: TOTAL A UNT:
TELEPHONE NUMBER: So 2-G 1 `Z 3 1 G
CONTACT PERSON: -V(-s S0-) 1pt ,r t I ✓' G
EMERGENCY CONTACT TELEPHONE NUMBER: 311 1 3 Z.-�- So '�- MSDS ON SITE?
TYPE OF BUSINESS: col
INFORMATION / RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed' / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
U"NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas
Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
. Miscellaneous petroleum products: grease,
Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages Wood preservatives (creosote)
Z Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Z C.� Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
1 Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may be toxic or hazardous (please list):
Metal polishes
Laundry soil &stain removers
(including bleach) f(�t , ,a) \eo W i
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
�-- r�SD l'rG1!GJ
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$40 O for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L.-it does not give you permission to operate.) ou mus't first obtain the necessary signatures-on this form at 200 Main St., Hyannis,
Take the completed form to the Town Clerk's Office, 1st FI., 367 Main St., Hyannis, MA 02601. (Town Hall) and get the Business Certificate that is ;
required by law.
DATE. n Fill in please:
!'' }is};� •'. ; ��',Yi` •Fz„! ': :I . APPLICANT'S YOUR NAME/S; 011
! •'trJJ ��
BUSINESS YOUR HOME ADDRESS:
1 '2 r 1 cl
TELEPHONE # Home Telephone.Number
d wa i c!o!L 411s1 Pfy?N� Y6
�''.:' .,vr,;,,tt:•;::ne;'r}ri;j:<•,;, #: E-MAIL: cc 1 fC'I �S� -4pf-MA - C 'U �
NAME OF CORPORATION:
NAME OF-NEW BUSINESS —2'tXIJ -TYPE OF BUSINESS cv��
1S THIS A HOME OCCUPATION? _YES NO
ADDRESS OF 8U5INE5S- . h �' 15 �'��" MAP/PARCEL NUMBER. �I - D UJ (Assessing)
When starting a new business thePe are.several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable. This form is intended to assist you in obtaining the information you may need. You MUST GO TO 20 ' St. corner of Yarmouth '
Rd. & Main Street)-to make sure you have the appropriate permits and licenses required to legally i5perate your busines hi
• . . \UST COMPLY �� H '�•OCCUPATION
1. BUILDING COMMISSIONER'S OFFICE RULES AND REGULATIONS. 'FAILURE TO
This individual has been f or fan per equiremerits.that pertain to thi type of business. COMPLY MAY RESULT IN FINI*�.
;
'J( uthoriz d Signat re*�G /
/ \ COMMENTS: `f `y� '
c C
�.
2. BOARD OF HEALTH
This individual has been informed of the e olit requirements that pertain to this type of business. MUST COMPLY WITH ALL
HAZARDOUS MATERIALS REGULATIONS
Authorized Signature*
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual has been informed of the licensing requirements that pertain to this type of business.
Authorized Signature**
COMMENTS: .
f
7/ -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
C-
47 Bishops Terrace r
,M Property Address N
V1
47 bishops Terrace RealityTrust
Owner Owner's Name
information is
required for every Hyannis ✓ Ma 02601 6/28/16
page. City/Town State Zip Code Date of Inspection LG
S�
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
f f
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Chad Hathaway
use the return key. Name of Inspector
H.P.S.
� Company Name
P.O.Box 151
Company Address
Forestdale Ma 02644
Cityrrown State Zip Code
774-274-2581 12866
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
6/28/16
Inspecto s Sign a Date
The system inspector shall s copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Q���s
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/28/16
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:
1000 gallon tank in good condition baffles in place no visable cracks or leaks. Dbox is clear of solids
no signs of being overful in the past.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
_y
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/28/16
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is 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
°M 47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owners Name
information is required for every Hyannis Ma 02601 6/28/16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS 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 pondin of effluent to the surface of the round or surface waters
9 9
❑ ® 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
47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/28/16
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ❑ The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•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 47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/28/16
_
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal
P systems?
P 9 P
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/28/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0-previous 1
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes 0 No
Last date of occupancy: feb. 2016
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
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M s 47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/28/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: unkknown
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/28/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
tank unknown Dbox and leaching 1997
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5'
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line. 3 feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
8,.
Depth below grade: feet
Material of construction:
0 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 gallon
Sludge depth:
2"
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
;M 47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/28/16
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
32"
1
Scum thickness
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
18"
How were dimensions determined? tape and sludge judge
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
pump every 2-3 years as maint. to protect leaching
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M 47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is
required for every Hyannis Ma 02601 6/28/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/28/16
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.):
camera inspected . clear of carry overs no visable cracks or leaks no signs of backing up in the past
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:
probed area no signs of hydraulic failure leaching is 2 500 gallon leaching chambers
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/28/16
page. City(rown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2
❑ 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.):
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 Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/28/16
_
page. Citylrown 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
;M 47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/28/16
_
page. Citylrown 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
c `
Ock
77-�/ /
y`
%,
ro
moo,
U
t5ins•3/13 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 47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/28/16
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 high ground water: 15'
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
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
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 47 Bishops Terrace
Property Address
47 bishops Terrace Reality Trust
Owner Owner's Name
information is required for every Hyannis Ma 02601 6/28/16
page. Citylrown 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
No. Fee. �C✓
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
3pprication for ]Digpool *pgtem Construction Permit
Application for a Permit to Construct('Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. L!7 131S 11,110-1 1 rl^146 15 Owner's Name,Address and Tel.No. 715-- 9 V y V
�Gi/1�t.6 �19f'f41{9�� l 1"Ol'1 S-e C 14
Assessor's Map/Parcel 4 S% 2 ,0(o e
27 dik&42s 11 ,vs
Instaaller's Name,Address,and Tel.No. -'17'7--o:?1_r q Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 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 .S.4",r Z
Nature of Repairs or Alterations(Answer when applicable)�i ZZ t vl /r)f>S Ti�l t� L/_7eG1ihri /-2j T u/,1
Gl 15N d
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 thjs Boar of Health.
Signed A. r Date /!- ! ._�7
Application Approved by ' Date
Application Disapproved for the following reasons
Permit No. Date Issued
S'
b sue- / / Y,� i' ..�_�No. "� !� �/ ��.'_ _ Fee s�.
' THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
4
Zipplicattori- for Migpogal *pgtent Congtruction Permit
Application for a Permit to Construct(s llepair( )Upgrade( )Abandon( ) ❑Complete System ElIndividual Components
Location Address or Lot No. 1�7 3 611 op,s 7'e r'/"k4G/ Owner's Name,Address and Tel.No.
Assessor's Map/Parcel " T A J/W I-f C wr o„ 17, '11:0h S-e c ig ,
2 sf 2 �G yq 3 ge-e H' <�,,s
Installer's Name,Address,and Tel.No. 4/77—o j t/q Designer's Name,Address and,Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
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 Alt rations(Answer when applicable) �l� /tl lax1 S'rJp7a L/:l9�lw«ri /0i
�64 ki l4 "o1 6,0 me,t6 y ',row
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 th' Board.ofHealth.
Signed Date /C- l,7 47
Application Approved by Date
Application Disapproved for 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( 4.rRepaired ( )Upgraded(` )
Abandoned( )by ( 5,e4A 0e 13o^-a C
at q!2 /.?i LO_j T-e -Afd _,ram has been constructed in accordance
.with the provisions of Title 5 and the for Disposal System Construction Permit No. - 4AK dated-4/--
Installer 7�
In 4.G 4?4 V e, rv-4!53 Designer 1 J10.5 r_PA, V.� ,?e0v"era 4
The issuance of this perquit shall//m�ot be construed as a guarantee that the.syste will function desi_ ed.
Date f / �!/ 7 Inspector-_,; � Z
r
---------------------------------
THE COMMONWEALTH OF MASSACHUSETTS Fee ltl;;e
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mwigpogar *pgtem Congtruction Permit
Permission is hereby granted to Construct( o,.)Repair( )Upgrade( )Abandon( )
System located at 7 131'3'4042 4 1-e�eva r Zo F_j;e Aso,y<t
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit. .'
Date: 7,- Approved b .r �7
j,a
.i 10/9/91
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
ENGINEERED PLANS)
17yj3t�r-"5' , hereby certify that the application for disposal works
construction permit signed by me dated it- /r— ?7 , concerning the
property located at meets all of the
following criteria:
There are no wetlands located within 100 feet of the proposed leaching facility
•(' There are no private wells within 150 feet of the proposed septic system
1-"'—There is no increase in flow and/or change in use proposed
4/There are no variances requested or needed.
• If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will n2l be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) ('8' _
B)Observed Groundwater Table Elevation(according to Health Division well map).5—
SIGNED: �..,n y_�17 1�! �y+hsh/ DATE: J/—/ —c/7
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 9'-1—
(Attach a sketch plan of the proposed system.Also if the licensed Installer posesses a certified plot plan,
this plan should be submitted].
q:health folder:cert
- o
xo9_0
-- _..._---- _ - --- -
'"f '%`" TOWN OF BARNSTABLE
SK` LOCATION` �/Sh un� T/j/'t�'p c� SEWAGE # f 7- G
61
VII.LAG E`<'<�/������� ASSESSOR'S MAP&LOT
INSTALLER'SNAME&PHONE NO.
SEPTIC TANK'"CAPACM /ODD
pe)
LEACHIIV,C•,•r::FACIUM (ty
2_saa�a� �Li.����,r (size)
NO.OF BEOPLOOMS 3
BUILDER-'.OR II..
PERMITDTE 1/717—QJ_COMPLIANCE DATE:
separation Between the:
Maximud'Adjusted Groundwater Table and Bottom of beaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist. Feet
on site;or:within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
i within 3.00'feet of leaching faci 'ty)
Furnished b .>.' ✓
' I i
�i P rrr�'L
Ala...........
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH ,
+ .d 14..dL ._ . ...... ...-. 0F_....��.9!�?!cc 5 �, 'G. .......................................
Appliration for i yoxial Workii Tonstrnrtinn ; rrntit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
•--•- 6 7
...---••...........................................................................................
Location-Address or Lot No.
�. ..: Address
..........•..... ....... ..........-----••-•---...................... ...-.._.........................--••--.....
.......... �$ 1�........ ..G l f9 .. ............ ...............•........................................._........_......_........................
Installer Address
UType of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms___....................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q, Other fixtures ............................................
W Design Flow__...._...,�i__.d.........................gallons per person per day. Total daily flow............. p.D__....................gallons.
WSeptic Tank—Liquid capacityAPCI_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 ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
,4 Test Pit No. 1.............:..minutes per inch Depth of Test Pit_................. Depth to ground water_--------_-----_-------.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
...........................................................----•-•------------------------•--••----.........................................................
0 Description of Soil.......................................................................................................................................................................
U -----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------.............
W
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
------.-•-------------------------------•----------------------------------------------------_.....-••-•--------•-------•-------------•-•---•--•---------------------------•---------•-......--••-•--•-
Agreement:
The undersigned agrees to install the afore scribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary de—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ssued by the oard healt .
Signed-- .. t •-•--•----•--- . AlliOV7 ...`..
Application Approved BY_____________��......e._.____G______ _ -�- ..
� Date
.................... a-te..............
Date
Application Disapproved for the following reasons_____________ -
--••-•......................•------------------------------------------- ...............................................................................................................................
Date
Permit No.._41;34....................................... Issued.------- ................................
e�
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF
<...e;:_Ii4 —........... .... OF..... Z, .........................................
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
f
................
F - t'� f ...
....... ::��.__. ._. " ._.r.. _.._...t: .....:, - ............ �...'��.. .....____..._..._......._......................_._______......_._.._...._.................._,
Location•Address or Lot No.
.................. .f .................. .........._.......................................................................................
p //s OV,ner / Address
....
Installer Address
UType of Building r Size Lot............................Sq. feet
�-, Dwelling=No. of Bedrooms........:r.................................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building .............................No. of persons............................ Showers ( ) — Cafeteria ( )
a Other fixtures .•---•--•------•------•-------
W Design Flow........... ...f.........................gallons per person per day. Total daily flow........... ': . ....................gallons.
9 Septic Tank—Liquid capacity_,tr-f-i.('gallons Length................ Width---------------- Diameter................ Depth.............
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......-9`< ... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) -11 / Dosing tank ( )
Percolation Test Results Performed bv.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water---------_.-_----------
f� Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_-.___-._____----_-----.
....•••....._..---••-------------•-•-•-••--..........-••••--•-•-- •--•-------- -•----•----.....-----........................................................
0 Description of Soil........................................................................................................................................................................
W
----------------------------------------------------------••------ --------- ----------•---••----•-------------------------------------------------•---•-••----------------------------••........---_..
V Nature of Repairs or Alterations—Answer when applicable.-----------------------------------------------------------------•----._------_-_-__------.---.
•••-----•----------•---------------••------•...••---•-- ._...--•--------..........................--------------------------------------------------.....----•'------......------.....---.........----
Agreement:
The undersigned agrees to install the afore described Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Ode—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been Issued by the Poard #healt•.
i • �''
Signedr- •--•--•-••----- --. _.--- . .. .
Date
Application Approved B
---------------
r Date
Application Disapproved for the following reasons:-------------- ........... ...................................................................................
................•-----••••-------•-••-----------------------••---•-••-------•-•---...--•--•-•-------..._...---------•--•-----•--------------------•------------•-...------•-•--•--•------ ...........
Date
Permit No.- Issued••- j,%..........................................Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
p
................
tiff
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
by............. ----- ..... ------� 1
y92 t I,�1 ta!1CC T l
at.............. � --f - }F a4: t j_--_--------------•---_-_•_-----_•----•----•------•--------_-_--_-_-------------••---_-_-___-_-____--
- ..-- �._._...___• s
has been installed,m-atc6-ic-lice with the protiisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No............ dated dated----.-..-.--_----______---._----_---____-----.--
xr e i
THE ISSUANCE OF THIS CERTIFICATE SHALL No
@�"��COMSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector......... ----_.........................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH ,
r ...... ...OF....... + _ ...........................
... 1 brY FEE........................
RaVviial Work wonotrartion rant$
Permission is hereby granted................
f..... f': _ :_ ...:
to Construct ( or Repair ( ) an Individual Sewage Disposal System'
f
at NO.............,-._.. ..... fy� r �. %.eX tt' ? _;/� L..l_
,., .......................:..................
Street
as shown on the application for Disposal Worl:s Construction -Permit TNV..e?-- ------- ---- Dated................................._........
•----------------------------- -----•---= ..........................................
Board of.;IIcslth� .
DATE......................................... ---------.........................
FORM 1255 HOBBS 2e WARREN, INC.. PUBLISHERS