HomeMy WebLinkAbout0027 ELDRIDGE AVENUE - Health 27 Eldridge Avenue, Hyannis
TOWN OF BARNSTABLE
LOCI T!^N a�T A qv - SEWAGE #
VILLAGE tJI C, ASSESSOR'S MAP& LOT '92 In
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Si ® s
LEACHING FACILITY: (type) P \ (size) 6
NO.OF BEDROOMS
BUII.DER OR OWNER
DATE: \ % V i� COMPI LANCE DATE:
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 wetlands exist
within 300 fe t of leaching facility) . . Feet
Furnished by
WNW
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• CONIMONWEALTH OF NjkSSACHUSETTS
r: EAECL•TIVE OFFICE OF DsxIRONNIE\TAL AFFAIRS
DEPARTMEIT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON. MA 02106 61 :9:•S:00
UILL1AM F.WELD F;.. . � TRL'"DQl'CG
Govcrnc• r ... r� BSc:rc.
c9 .'DAN'ID B-=STRL•
ARGEO PALL CELLUCCI Conunissic
Lt.Governor��II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR�+t
PART A
CERTIFICATION u ,�
LOT " °� —.kxY-,t NN)� t+., dress of Owner:
Property Address;\� � ti S fc,t-K Address
Date of Inspection: �\w\% 62t7U 1 'qf different)
Name of Inspector: .o A 11 E-1)(a,,Ce�
1 am a DEP ap roved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 13.000)
Company Name:�/7o vr4-,-a 057n a'', -, 0"���/
Mailing Address: _'Pe-) 1;=x C_3Z 4A H AsAoeLL H /`r O 2E4-q
Telephone Number: L¢•
CERTIFICATION STATEMENT
I cer:ifl that I have pe•sonally irspec:ed the sewage disposal syste at this address and tha: the information reaoned be?o% is true. accurat
and comolete as o:the time of inspec:.o The mspec:xn was pe':ormed bases on my training and experience in the proper iuneicn and
maintenance o-*on-s-te sewage disposa; systems. The wsterm
Passes
_ Concioonaii% Passes
Neecs Funhe• Evaluaro^ Ey the Local Approving Authonn
—' F a ,i .
Inspector's Signature. Date:
T;ie Svs:e-r Ins_e o• sha'' submit a cop\• of this inspeC.en recc.; to the Aporoving Authoriry within thirty (301 days of completing this
inspecion, It the wstern is a share: !\•stem o• has a de:-gn now of 10.000 god or greater, the inspector and the syste•r. owner Shall subm:
the repo-: to the aaoropriaie regional o-Hice of the Depan.ment of Envirenmenta' Frote,for. The crig:na! should be se-.I to the system o,r
and copes s--a to the buyer, ii applicable, and the approving authority
INSPECTION SUMINV%RY: Check A, B, C, or U
Al SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defines' in 310 C.MR 15.3C
Any failure criteria not evaluated are indicate^ below. .
COMMENTS:
BI SYSTEM CONDITIONALLY PASSES:
One or more system components as described in the 'Conditional Pass- section need to be replaced or repaired. The system, uc
completion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not determined (Y. N. or NDi. Describe basis of determination in all instances. If'not determined-, explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (anached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection;
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or t:
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic can;
w approved by the Board of Health,
trev:.s-d 0//2:!31) Page 1 of 10
a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECT10% FORM
PART A
CERTIFICATION (continued)
Property Addws:
Owner:
Date of Inspection:
B]SYSTEM CONDITIONALLY PASSES (contin,,,ft'
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipets) or due to a broken, sealed or uneven distribution box. The system wi pass inspection if approval of the
Board of Health). Describe observations:
broken pipets) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system requires pumping more than four times a year due to br ken or obstructed piWsl. The system will pass
inspection if twith approval of the Board of Health):
broken pipets; are replace
obstruction is removed
C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require furthe• evaluation by the Board Health in order to determine if the iystertt is failing to protec t-a-
public health. safe-,.-and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETE INES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SA AND THE ENVIRONMENT:
Cesspool or pna ,s within 50 fee: of a sumac water
Cesspool or priv-v is within 50 feet of a bor ' ring vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF H LTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THE.-
THE SYSTEM IS FUNCTIO%I.NC IN A MANNE THAT PROTECTS THE PUBLIC HEALTH AND SAFE Y AND THE
ENVIRONMENT:
The system has a septic tank and ii absorption system (SAS) and the SAS is within 100 fee: to a surface water supply a-
tributary to a surface water supply.
The system has a septic tank a soil absorption system and the SAS is within a Zone I of a public water supoty well.
The system has a septic tank d soil absorption system and the SAS is within 50 feet of.a private water supply well.
The system has a septic tan and soil absorption systern and the SAS is less.than 100 feet but 50 feet or more from a
private water supply well, niess_a we!I water analysis for coliform baeeria and volatile organic compounds indiates
the well is free from poll tion from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal tc c-
less than 5 ppm. Meth used to determine distance (approximation not valid).
3) _ OTHER
(revise) s.4. 2 of 10
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART.A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
Dj SYSTEM FAILS:
You must indicate either "Yes" or "No' as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contaaed to determine what will be necessary to correct
the failure.
Yes No
Backup of sewage into facility or system component due to an 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.
Sta:ic !squid level to the distribution boa 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 1/2 day floe.
Recuired pumping more than, 4 times in the last year NOT due to clogged or obstruaeo pipes .
Number of times pumped _.
Anv portion of the So!l Absorption System, cesspool or privy- is below the high groundwater eievanoc
Am por:,on of a cesspool or privy is within 100 feet of a surface water suppiv or tributary to a surface water supply.
Any portion of a cesspoo' or privy is within a Zone I of a public well.
Am pcnion o�a cesspool or prig is within 50 feet of a private water supph well
Anv por.or. O'a cesspool or pricy is less than 100 feet but greater than 50 fee! from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable. anach cope of well water analysis for
cohiorm bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes` or -No" as to each of the following:
The ioliow:r,g criteria appi,6 to largo systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to
public hea!th and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area - IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04/25/97) Page 3 of 10
f
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: slm.,Ac1_
Owner: NmoN'
Date of Inspection: 9,o
Check if the following have been done: You must indicate either "Yes" or 'No" as to each of the following:
Yes do
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
_ As butt, plans have been obtained and examined. Note if they are not available with N;A.
The facalm or d%ve►ling was inspected for signs of sewage back-up.
}( _ The s%-stem does not receive non-sanitary or industrial waste flow.
The site %%as inspected for signs of breakout.
_ All s%'sterr co nponents. excluding the So+l .Aosorpuon System, have been located on the site.
The septic tank manho;es mere uncovered. opened. and the interior of the septic tank was inspected for condition of
-+� baffies or tees. materta; o' construction. dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on"
The iac,lw, o%.ne• %ano occupants. if dtfterent from owneri were provided with information on the proper maintenance of
-"t Sub-Suriace Disposal System.
Existing tniormation. Ex. Plan at B.O.H.
Determined to the field !tf an, of the failure Criteria related to Part C is at issue, approximation of distance is
unaccea:abie 115.302.3t:bil
(revised 04/25/5?i page 4 of 10
16
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
G SYSTEM INFORMATION
Propert,. Address: 1�—
Owner: ill� p�J
Date of Ihspection: a 1,u1��
V' 1 FLOW CONDITION'S
RESIDENTIAL:
Design flow. 4114D g.P.d./bedroom for S.A'S
Number of bedrooms q
Number o?current residents-
Garbage g•:--der (yes or not: (J
Laundry cor-ected to system (yes or no!.
Seasonal use ryes or no!: K)
Water meter readings. if available (last two :2 year usage (gpd):
Sump Pump (ves or no)-
Lac date of occupancy
COMMERC i 4L'INDL'STRIAL:
Type of establishment
Design fio%% fzahonsida�
Grease trap present Ives or no_,
Indusiria! %I aste Holding Tani; present. Ives or no_
':on-sanitan Haste discnargea to the Taie 3 systern, wes or no
\%ater meter readings, if availabie
Las:pa;e o; o ":Panc.
OTHER: Describe
Last sate of occuoanc.
GENERAL INFORMATION
PUMPING RECORDS and source of information
011N01!6t t ! &S PPIM?
System pumped as par, of inspection: Ives or no.-No
If yes, vo:ume pumped ¢allons-
Reason for pumping
TYPE OF SYSTEM
Septic tank/distribution box!soil absorptions stem�1
Single cesspool I I 1S= -Vt Tl
Overflow cesspool
PrnI-
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
APPROXIMATE AGE of all components, date installed (if known) and source of information:,. Ili
Sewage odors detected when arriving at the site. (yes or no) �
(revimed 04/25/9'7) Page 5 of 10
n
i
SL.'BSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade.
Material of construction.._cast iron _40 PVC_other (explain
Distance from private water supply well or suction I;-t
Diameter
Comments: (condition of joints, venting, evidence of leakage. etc.)
SEPTIC TANK:_
(locate.on site plan
Depth below grade
material of construction: _concre'e _me:a _Fioerglass _Polyethylene /hertexplain
If tani, ;s metal. I;s: age _ Is age.cor.f,rmec o� Ce^:fica:e of Compuance (`res'!No
Dimensions
Sludge depth
D;siance from top o: s!udee to bortom of outie: tee o, ba�:e
Scum thickness
Distance from top of scum to top of outle: tee or ba^ie
Distance from bottom of scum to bo-o-n o;outlet tee er bar.'
Now dimensions were determined
Comments
trecommendation for pumping. condition of inlet and utlet tees or baffles. depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage. e:c.;
GREASE TRAP:
(locate on site plan:
Depth below grade:
Material of construction: _concre _metal Fiberglass _Polyethylene _other(explain)
Dimensions:
Scum thickness:
Distance from t/pumping,
p of outlet tee or baffle.
Distance from bo bottom of outlet tee or baffle:
Date of last pum
Comments:
(recommendatio condition of i let and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
;ntegnty, evidentc.:
lrwy��� 0�/75:97) Page • of 10
' t
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMAT10% (continued)
Propert. Address: '
O%ner.
Date of Inspection:
TIGHT R O HOLDING TANK: Tank must be pumped prior to, or at time, of inspeaioni j
(locate on site plan,
Depth below grade
Material,of construction.' _,concrete _metal Fiberglass _Polyethylene _other(explain)
— I
Dimensions:
Capacuy gallons
Design floe galions.da.
Alarm level A:am in "orking order_ Yes. _ No
Date of previous pumping
Comments _
(condition of inlet tee. condition o! ald,m and float switches. etc.)
DISTRIBUT10% BOX:
(locate on site pan
Death of licuid level aoove outle: in.e,7
Comments
mote of leve! and distributior is eaua, evidence of so ds carryover, evidence of leakage into or out of box, etc.l
PUMP CHAMBER:
(locate on site plan._
Pumps in working order: (Yes /No-
Comments: No,
Alarms in working order (Yes
(note condition of pump chainpumps and appurtenances, etc.)
(revised 04/25/97) lags 7 of 10
n-
4
` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO..Rtii
PART C
SYSTEM INFORMATION (continued)
Property Adrfr-ss:
Owner: r-a
Date of Inspection;A,, ,C�b
SOIL ABSORPTION SYSTEM (SAS):u
(locate on site plan, if possible, exca%ation not required. but may be approximated by non-intrusive methodsi
If not determined to be present, explain:
Type:
leaching pits. number.
leaching chambers, number:_
leaching galleries, number.
leaching trenches, number,tength:
leaching fields, number, dunensio.n.s
overflow cesspool, number
Alternative system
(game of Technology
Comments
mote condition of soil, signs of hydraulic failure. level. of ponding, condition of vege atio etc.' a
O IN (T
CESSPOOLS:
(locate on site p ar.
Number and coniigura:,or tJ
Depth-top of liquid to inlet Inver, I
Depth of solids lave- &
Depth of scum laver. ;Q v
Dimensions of cesspool 4;1IA Y T r
Materials of constructior C (1W—VJ T-,- .),:x
Indication of groundwate• t,�G
inflow (cesspool must oe pumpec,as par, of inspection's_'" Nth
n Comments.
(note condition of soil, signs of hydraulic failure, level of ponding, condition f vege to etc.)
Jot_ I Gr VWi; T C(7 V-%,&►C�I�. 'IQN�MO C,rr 1�2f fA
v
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.)
(revised 04/25/97) Pag• 8 of 10
c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
��A 1 SYSTEM INFORMATION (continued)
Property Address aj
Owner:(Nf(SO P
Date of Inspection:��'Or��
11
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained irom Design Plans on record
Observation o`Site (Abutting property. obsen•ation hole, basement sump etc.)
Determine it from local conditions
Cnec" %.ah loca! Board o• nea!tr
Chec: FE.NAA maps
Check pumping records
Check local excavators. installers
L•se L5C5 Da:z
Describe in voi• o%•-. %%oral r.o,.% %o;: es:abhshed the High Groundwater Elevation. tMust be completed•
S• 54ol0SiCOD y� I Lf—A c�(�-J+JvesT m-�lowSi U,P, SZ. 5 3
lrevcs.d 04;251s- Page 10 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continuedi
PropertN Address:
Owner: Pt4.lJ1�
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
xt 2-1
O �
Ai _
t7 s
(revised 04!25/9') Page 9 of 10
°35 Eldridge-Avenue
I Hyannis , `F/R
\A = 292' 059
0
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 35 Eldridge Avenue
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is August 29, 2008 Hyannis MA 02601 Au
required for H Y g
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.
'mp°'`q"t
When filling out A. General Information
forms on the I 5 I�
computer, use 1. Inspector:
only the tab key
to move your David D. Coughanowr
cursor-do not Name of Inspector
use the return
key. Eco-Tech Environmental
Company Name
43 Triangle Circle
Company Address
Sandwich MA 02563
City/Town State Zip Code
508 364-0894 1328
Telephone Number License Number
B. Certification rw
CD
I certify that I have personally inspected the sewage disposal system at this ad ss andWpt then
information reported below is true, accurate and complete as of the time of the*:. pection"-The i5 pection
was performed based on my training and experience in the proper function an ainten re ofc�.n site
sewage disposal systems. I am a DEP approved system inspector pursuan Section 15.U.0 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ ils CID
w m
❑ Needs Further Evaluation by the Local Approving Authority
IGS August 29, 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 the future under
the same or different conditions of use.
L,9 1/5
t5-3012.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
35 Eldridge Avenue
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is H August 29, 2008 annis MA 02601
required for y
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:
® 1 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.
13) 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
t5-3012.doc•08106 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
35 Eldridge Avenue
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is H August 29, 2008 annis MA 02601
required for Y
every page. City/Town State Zip Code Date of Inspection
a'
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
❑ 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.
t5-3012.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M , 35 Eldridge Avenue
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is Hyannis MA 02601 August 29, 2008
required for Y g
every page. Cityrrown 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 '/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.
❑ Z Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
t5-3012.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
f
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Eldridge Avenue
�M
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is August 29, 2008 Au Hyannis MA 02601
required for H Y _ 9'
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-
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.
t5-3012.doc•08/06 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
35 Eldridge Avenue
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is Hyannis MA 02601 August 29, 2008
required for _Y g
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the followinghave been done. You must indicate "yes" or"no" as to each of the following:
Y 9
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ N 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?
Leaching gallery
also evaluated ® ❑ 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)]
15-3012.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Eldridge Avenue'
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is August 29, 2008 Hyannis MA 02601 Au
required for H Y g
every page. City/Town State Zip Code Date of Inspection
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 gpd
Number of current residents: 3
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 501 gpd
9 ( Y 9 (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: current
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:
Last date of occupancy/use: Date
Other(describe):
t5-3012.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
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Eldridge Avenue
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is Hyannis MA 02601 August 29 2008
required for y g
every page. City/Town 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
❑ Single cesspool
I!I ❑ 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: 3+years. Cartificate of Compliance issued 1012512004 (Board of Health permit#2004-562)
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5-3012.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Eldridge Avenue
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is August 29, 2008 Hyannis MA 02601 Au
required for H Y g
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2feet
Material of construction:
® cast iron ❑ 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
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: 10.5 ft x 5 ft x 5 ft(1500 gallon)
Sludge depth: 4 in
Distance from top of sludge to bottom of outlet tee or baffle 30 in
Scum thickness 2 in
Distance from top of scum to top of outlet tee or baffle 9 in
Distance from bottom of scum to bottom of outlet tee or baffle 13 in
How were dimensions determined? As built card
t5-3012.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
35 Eldridge Avenue
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is nnis MA 02601 August 29, 2008
required for H a Y 9'
every page. CityTTown 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 not required at this time but maintenance pumping is recommended within and every two
years. Tank and tees appear structurally sound and functioning as intended. No evidence of leakage
in or out was observed.
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
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):
t5-3012.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
35 Eldridge Avenue
'M
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is August 29, 2008 Au Hyannis MA 02601
required for H Y _ g
every page. Cityrrown State Zip Code Date of Inspection
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 At 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 appears structurally sound with no evidence of leakage in or out. Some solids in sump.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5-3012.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
r
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 35 Eldridge Avenue
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is required for y H annis MA 02601 August 29, 2008
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (nose condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
® leaching galleries number:
1
❑ 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 gallery appeared unsaturated. No evidence of surface ponding, breakout, lush
vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into
leaching gallery stone and no effluent contact staining was observed in the stone or overlying soils.
No standing effluent was observed in the top 1 foot of the stone.
t5-3012.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Eldridge Avenue
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is Hyannis MA 02601 August 29, 2008
required for Y 9'
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.):
t5-3012.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts(
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Eldridge Avenue
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is August 29, 20082 MA i anns 0601 Au
required for Hyannis g
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.
LEACHING CALLERY LOCATIONS
0 o: o
A B
20 D-Box 1 36.5 FL 30 FL
2 53.5 FL 60 ft
10 0
3 56.5 Ft 61 ft.
1
SEPTIC
TANK
B A
EXISTING
DWELLING
# 35
W
Z
J
W
W
F
Q
3I
EL_ DRIDGE RDAD
NOT TO SCALE
t5-3012.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
N, Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
35 Eldridge Avenue
Property Address
Rosemary Willis and Helinton Dasilva
Owner Owner's Name
information is Hyannis MA 02601 August 29, 2008
required for Y 9'
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to 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.
t5-3012.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
TOWN OF BARNSTABLE
LOCATION LLB �(- ,� A VI:/ SEWAGE#
VILLAGE ASSESSOR'S MAP&LOT '
INSTALLER'S NAME&PHONE NO. V 7O /
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type)3"A-Q&/� :30 6 S (size) A-35 7t(7,(2
f 2-
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility �U�/� Feet
Private Water Supply well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) / /v Feet
Furnished bye? NCO
-Sy
l- z
i l �cn
No. Fee I
THE COMMONWEALTH OF MASSACHUSETTS '�`' Entered in computer:
Yes
PUBWC HEALTH DIVISION -TOWN OF BARNSTABLE,, MASSACHUSETTS
Zipplication for Migool *pztem Construction Permit
Application for a Permit to Construct( . )Repair(A_U1_P`g rade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. O er's Name,Addr ss#nd Tel.No.
Assessor's Map/Parcel 02 pr-� �^p
Installer's Name,Add Designer's( Designer's Name,Ad ress and Tel.No.
AA ; EE33 GGAA IVeyLr g
350 Main Street l
7�/• SBS oaF
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 33 gallons.
Plan Date /-0•y' Y Number of sheets l Revision Date 16 ' //• �/
Title .�i ft — Tt t.,A S e
Size of Septic Tank /.SOO Type of S.A.S.
Description of Soil r P ✓1
Nature of Repairs or Alterations(Answer when applicable)
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 Env' onmental ode and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board o H alth.
Signed Date �d •�
Application Approved by .? Date
Application Disapproved for the following reasons
(7—
Permit No. Date Issued
-/�+e.✓'-��.... ._.-,r{-''.:.��j. . ».,, .r'1. .�H.-"*ti-.4.�;r.rr '�;.. .,,�- .. �.�s�,�—.«:y.c .. ` •,.G+'v;a-tro.-'." -�••r.,s:.!-+AY.i "i' 'a - e'�v ... .,.-.i, -r r-
4 F '^ter
'",�"� �'-•tee t Fee
�.:
Nod; THE COMMONWEALTH OF MASSACHUSETtfS' "- Entered in computer:
. r. a Yes
LPUB ``C HEALTH DIVISION'-,TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for Zie;paar *pttem Con!61' uction Permit
Application for a Permit to Construct( )Repair(/rpgrade( )Abandon( ) El Complete System ❑Individual Components
Location Address or Lot No. 3� T 1 Ow er's Name,Address and Tel.No.
fe
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
41) e-
Type of Building:
Ei� { DwellingM`--No.`df Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type'of>Building . No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow i�� gallons per day; Calculated�daily flow �-3 O gallons.
Plan Date ��' ��' y Number of sheets � / a rRevision Date
_ Title .Tif�' - fcwAc e
Size of Septic Tank / $-OU Type of S.A.S.
Description of Soil rC
Nature of Repairs or Alterations(Answer when applicable)/Xi f'7
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 Env' onmenta Gode and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Board o H alth. ++ /
Signed . / r! / 1 �� /� Date 1, C(/
Application Approved by4V Date
Application Disapproved for the following reason V v
/ 4
Permit No. /Date Issued t /drWv
———————————. ———
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
_. ., THIS_IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( ) Repaired (6,--)-15 graded( )
Abandoned( )b
at 35 e d rl wc,,e /. .4s 7i J S haasJ)e�e,n constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. �'�rTdated
Installer Designer
The issuance of this permit shall n t be construed as a guarantee that the s emTgilmNtioas designed.
Date Z4 &�5 V Inspector i
No.— !-71 ---------------.--------Fee /ub
���CCCJJJ THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Migooal *potem Construction Permit
Permission is hereby ranted to Con ruct ) Repair(`/�)UpgradleS, )Abandon( )
System located at ��'
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.
completed within three years of the date of tti' 'permit Provided:Constructions must b0 j
Date:_�� i1 / Approved by f
e
} r" .,* Xwl-g .._ . F, r�;
wr
3� ��
�} � � ^ Y`=< �L $`%�.t�.'i-^s"'�ti ,.. ,�"•- ." ;' x��x� 'sr is ` a t �"��`s � �n
a ,fi W .: = ThamasF Geller Director h � �
+l • �.;
9 �ubl�c Health ORI'sion '
z�k"yF f .-� r VAR;
�t� r
ThomaS McKFean,D Ctol'":, x" w M,i �
? ,Sit ,,rs.ni2s,ra � "�"-`e?tix.+ s. �'X'"`'
ain ) �E`'.
�x 200 M Street,=Hyans;MA�02601 <3' ``� F , "
Office' 5. 08 862-4644 rFaa 508,794.6�304 '
Install r &1 e91�ner,Certifcation FOr1Yi
Date: 10 2
Designer: f tLJ / Installer: f ��it�C0
Address: P pX ��� Address:
56tj 16114 03 7 G�. yice�ivrl
On �Af a was issued a permit to install a
(datey (installer)
septic system at�?jrj ( �D � � based on a design drawn by
i (address)
dated __ o)Szv
(designer)
T-certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved-changes such as lateral relocation of the
distribution box and/or septic tank.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system)but in accordance with.State&Local Re ations. Plan revision or
certified as-built by designer to follow.
�JZN Of Mgss
9
DA E ctiGN
A F_ Cn
(Ins taller's Signature) �-- , 1140
� o
1 STE��
SgNI.TAR\P� .
b�
(DesipeYs Signature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CE RTIFICATE
OF COMPLIANCE WILL'NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE.BARNSTABLE PUBLIC HEALTH DIVISION.
TANK YOU.
Q:Health/$eptidDesigner Certification Form
' COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 35 Eldridge Avenue ASSESSORS MAP NO'
Hyannis, MA 02601
Owner's Name: Rose White PARCEL NO:
Owner's Address:
•ON130a`dd
Date of Inspection: June 26, 2004 •ON dosHOSS3SSd
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford
Mailing Address: P.O. Box 49 ll JA�
Osterville,MA 02655-0049 � fspE
Telephone Number: (508)862-9400 �rIOI V
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of 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
Needs urther Evaluation by the Local Approving Authority
✓ Fails
Inspector's Signature: Date: June 28, 2004
The system inspector shaNsubmia 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.
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 page 1
Page 2 of 1 1
s OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 25 Eldridge Avenue
Hyannis, MA
Owner: Rose White
Date of Inspection: June 26, 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 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass" section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
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
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:
2
�r
Page 3 of 1 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
r PART A
CERTIFICATION (continued)
Property yAddress: 25 Eldrid3ze Avenue
Hyannis, MA
Owner: Rose White
Date of Inspection: June 26, 2004
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
2. System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria 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:
3
Page 4 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
` PART A
CERTIFICATION (continued)
Property Address: 25 Eldridge Avenue
Hyannis, MA
Owner: Rose White
Date of Inspection: June 26, 2004
D. System Failure Criteria applicable to all systems:
You must indicate either"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 '/z 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.
✓ 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 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.]
Yes (Yes/No)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 System:
To be considered a large system the system must serve 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 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.
4
Page 5 of 1 I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 25 Eldridge Avenue
Hyannis, MA
Owner: Rose White
Date of Inspection: June 26, 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 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 ?
n/a 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:
Yes No
✓ _ 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(3)(b)].
5
i
Page 6 of I 1
` OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 25 Eldridge Avenue
Hyannis MA
Owner: Rose White
Date of Inspection: June 26, 2004
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): n/a 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: 1
Does residence have a garbage grinder(yes or no): Yes
Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,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: Pumped 1 year aw-per owner
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 a 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
6
Page 7 of I I
k
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 Eldridge Avenue
Hyannis, MA
Owner: Rose White
Date of Inspection: June 26, 2004
BUILDING SEWER(locate on site plan)
Depth 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 on site plan) Cesspool acting as a septic tank
Depth below grade: Cover to grade
Material of construction: _concrete _metal _fiberglass _polyethylene
✓ other(explain) Cesspool block
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 5'W x 5'T x 7'bottom to grade
Sludge depth: --
Distance from top of sludge to bottom of outlet tee or baffle: --
Scum thickness: --
Distance from top of scum to top of outlet tee or baffle: --
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Liquid was above both the inlet and outlet pipe backing up from the leach field.
GREASE TRAP: None (locate on site plan)
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.):
7
1 Page 8 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 EldridQe Avenue
Hyannis, MA
Owner: Rose White
Date of Inspection: June 26, 2004
TIGHT or HOLDING TANK: None (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: jzallons
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: None (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.):
PUMP CHAMBER: None (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.):
8
Page 9 of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
v
PART C
SYSTEM INFORMATION (continued)
Property Address: 25 Eldridge Avenue
Hyannis, MA
Owner: Rose White
Date of Inspection: June 26, 2004
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: I -6'x 6'
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
✓ overflow cesspool,number: 1
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.):
The leach pit was full and liquid was above the top ofthe pit The pit was in failure The cover was 2'below grade The overflow
cesspool was not dug up
CESSPOOLS: None (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: None (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:):
9
t Page 10 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
If
Property Address: 25 Eldridge Avenue
Hyannis, MA
Owner: Rose White
Date of Inspection: June 26, 2004
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.
A Q
3'1 30
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)
Property Address: 25 Eldridge Avenue
Hyannis, MA
Owner: Rose White
Date of Inspection: June 26, 2004
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
_Using Barnstable topographic maps and water contours map the maps were showing approximately 25'+1-to ground water
at this site.
This report has been prepared and the system inspected and failed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
i•
.............
• a
'y ' .ASSESSORS MAP: 2R2 TEST HOLE LOGS _ .NOTES: .
PARCEL : �A 1) THE INSTALLATION MUST BE IN SUBSTANTIAL COMPLIANCE WITH
SOIL EVALUATOR : !"l P� 5 ` C5� HIS PLAN, 1995 MASSACHUSETTS TITLE V & TOWN OF
' FLOOD ZONE: NON R�YZq-{_gyp
BOARD OF HEALTH REGULATIONS.
_ WITNESS: . ECIJtI�fl
REFERENCE: BY.- �5 3 DATE: SepIEm&E✓ "zol W04- 2) THE INSTALLER SHALL VERIFY THE LOCATION OF UTILITIES,
14, �4 PERCOLATION RATE: ` L / SEWER INVERTS AND SEPTIC COMPONENTS PRIOR TO
CA - F. ,Ka as , I�Y,E : CbASS r SDI!.S L�Tl9�a 0,7Y U pd(rs� INSTALLATION.
rm Su� ��� TH- I E TN-2 3) THIS PLAN SHALL BE USED FOR SEPTIC SYSTEM INSTALLATION
q �• f7
O ONLY, AND SHALL NOT BE USED FOR PROPERTY LINE
l'FLllw ot N� ��►r7 kk. �E S. LOAN►� � --�- A S�`/ �bv;ZS�1 _ � DETERMINATION. .
.. T. UNLESS
4) ALL PIPING TO BE 4 SCHEDULE 40 @ 1/8 / FOOT.
LO Pc rAq _ SPECIFIED OTHERWISE)
LOCATION MAP , .0,
N I 5) THE DESIGN OF THIS SYSTEM DOES NOT ALLOW FOR THE USE OF A
GARBAGE DISPOSAL.
6) SEPTIC TANKS AND DISTRIBUTION BOXES (WHEN INSTALLED)
(2i 5019 C MUST BE PLACED ON A MECHANICALLY COMPACTED BASE OR ON
-7+ 13.�7 A BASE of 6"OF CRUSHED STONE.
�1 7) FXIS17�4 6655 Pbatr -Da�M I°�(D�G SH fl
ELDRIDGE A VENUE 8) No oJowly Po4 J47F— W eL.LsW � J 'or- PADP. LE40f .
EDGE OF PAVEMENT S E P-1 I C S 1-S)T E M DES I G N I. /Vo WF1 t "19S 1 nl Ib1 DT- Fp o f, LEAUt-Y N
K .
80.00 Ft Q� FLOW ESTIMATE � � I�. o CESHeOM _11'ft V ok p�
_ 3 BEDROOMS AT I GAL/DAY/BEDROOM - r°I� GAL/DAY bfl ST�i -E h�3oA � o �f_ �
SEPTIC TANK.
GALIDAY x 2 DAYS - GAL -
w � Im USE GALLON SEPTIC TANK -
., b_ idE1A)
SOIL ACSORPTION SYSTEM
E.�:,) _ 305-0 IN FI UTRPkThp_ yo rFTs W14'5TbOE O P
_ Tlt\l +ts I. s �-5 oAJ EaJ � 26.3.S�l.k.
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Q SIDE AREA: ��[�.35'}2 +-LIZ.12���k Z. 0.7 3 . q
w TOP OF FNON
EL BOTTOM AREA: 2/,.SS-•SS' k M.1 X ��9q = 23G. 3
I v - 44.63+- �
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-— CESSPOOL- SEPTIC SYSTEM SECTION
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-ro F : EL F.e3
BENCH MARK rn �
CORNER CONC SLAB A � '
ELEVATION = 48.57 Ar� �BRt,Y1 S TO
S DATUM ASSUMED L
w/lN 6 'o finrsL, El-
Ott . 476-4$,
USG i4 rode
o', I 4 :$7 `9 4 Ins
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o I .IL „S,I,r,,� 44. I Z
- Sow GAL -Box 4+37 43.�z
SEPTIC TANK /ne55� .
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AREA 28 2 g �asl+cr�
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48 �
80.44 {r sqVITAP►s7E0 PREPARED FOR : �l>S� INtIIT
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0
SCALE :
/1 DARREN M. MEYER, R.S.
DATE:/o 0
� 43 VINE STREET —��-
ID
DUXBURY, MA 02332 ff V.U
DATE HEALTH AGENT (781) 585-0293