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Home My WebLink About0116 SAINT CATHERINE AVE - Health (2) 116 ST., CATHERINE AVE. HYANNIS A = I scapt- I 1 / Commonwealth of Massachusetts c2 9` 0 4-9 p, Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments !% 116 SAINT CATHERINE AVE i Property Address BRENDA MORECRAFT Owner Owner's Name / information is required for every HYANNIS f✓ _MA _02601 12/8/2020 _ --- 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 out forms A. Inspector Information on the computer, use only the tab Christopher Maki key to move your Name of Inspector cursor-do not Cape Cod Septic Services use the return key. Company Name 350 Main St. raa Company Address W Yarmouth MA 02673 City/Town State Zip Code srma 508-775-2825 _SI-14423 Telephone Number License Number B. Certification . 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; nd 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: s 1. ® Passes 2. ❑ Conditionally Passes. ` 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 12/10/2020 Inspector's Signal: 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. 15insp.doc-rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts ; - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 SAINT CATHERINE AVE Property Address BRENDA MORECRAFT Owner Owner's Name information is required for every HYANNIS - MA 02601 12/8/2020 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: SYSTEM IS IN WORKING CONDITION t - 2) System Conditionally Passes: 1 ❑ 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): t51nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface.Sewage Disposal System Form -Not for Voluntary.Assessments 116 SAINT CATHERINE AVE Property Address BRENDA MORECRAFT , Owner Owner's Name information is required for every HYANNIS MA 02601 12/8/2020 page. City/Town 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 =1 — 4 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 SAINT CATHERINE AVE Property Address t BR_E_N_D_A MORECR_AFT Owner Owner's Name information is required for every HYANNIS MA 02601 12/8/2020 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 attache d.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 t'5.nsp aoc•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 1?, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 SAINT CATHERINE AVE Property Address BRENDA MORECRAFT Owner Owner's Name information is required for every HYANNIS MA _02601 12/8/2020 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 I ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 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. ❑ ® 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.] ❑ N 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 i ❑ ❑ 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 ❑ El 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 N ,1p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 11_6_S_A_INT CATHERINE AVE Property Address BR_EN_DA MORECRAFT Owner Owner's Name information is required for every HY_ANNIS MA 02601 12/8/2020 _ _- _ page. City/Town 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 an 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)] :film,.nr c•rev 712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form - =I Subsurface Sewage Disposal System form -Not for Vol untary"Assessments 116 SAINT CATHERINE AVE ~J Property Address BRENDA MORECRAFT Owner Owner's Name information is required for every HYANNIS MA 02601 12/8/2020 - page. City/Town 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 Description: Number of current residents: 3 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, 18- 15 if available(last 2 years usage(gpd)): �1 - 11 GPD GPD Detail: f Sump pump? ❑ Yes 0 No Last date of occupancy: CURRENT Date i5nsp ooc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts ,P Title 5 Official Inspection Form 4 Subsurface Sewage`Disposal System Form -Not for Voluntary Assessments r; a �q � 116 SAINT CATHERINE AVE Property Address BRENDA MORECRAFT Owner Owner's Name information is required for every HYANNIS MA 02601 12/8/2020 -- 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): t 3. Pumping Records: Source of information: N/A Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? c 1 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 ;Es Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 SAINT CATHIERINE AVE Property Address BRENDA MORECRAFT Owner Owner's Name information is required for every HYANNIS MA 02601 12/8/2020 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: 1999 PER PERMIT ON FILE AT BOH Were sewage odors detected when arriving at the site? k ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth-below grade: 1911 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+ feet Comments (on condition of joints, venting, evidence of leakage, etc.): LINE CHECKED WITH SEWER CAMERA AND WAS FOUND TO BE CLEAN AND PROPERLY PITCHED t5msp uoc•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 1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 SAINT CATHERINE AVE V Property Address BRENDA MORECRAFT Owner Owner's Name information is required for every HYANNIS MA 02601 12/8/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): ..Depth below grade: 1211feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 GALLONS Sludge depth: / 211 Distance from top of sludge to bottom of outlet tee or baffle Scum thickness 21' 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? ESTIMATED Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000 GALLON TANK IN GOOD CONDITION. PVC TEES IN PLACE AND CLEAN. TANK AT NORMAL OPERATING LEVEL. COVERS 12" BELOW GRADE 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments =i 116 SAINT C_ATHERINE_A_VE Property Address BR_ENDA MORECR_AFT Owner Owner's Name information is HYANNIS MA 02601 12/8/2020 required for every _ ....__. -I..----___._____-_____. 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): 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: P Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): r Dimensions: Capacity: gallons Design Flow: gallons per day 15,nsp doc-rev 712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts } =- 4 Title 5 Official Inspection ' Form ''i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 SAINT CATHERINE AVE Property Address BRENDA MORECRAFT Owner Owner's Name information is required for every HYANNIS MA 02601 12/8/2020 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): i Depth of liquid level above outlet invert EVEN Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): DISTRIBUTION BOX LEVEL AND WATERTIGHT 45insp ooc•rev 7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 SAINT CATHERINE AVE Property Address BRENDA MO_R_E_CRAFT Owner Owner's Name information is required for every HYANNIS MA 02601 12/8/2020_ page. City/Town 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: ti Type: ® leaching pits number: 1-6X6 PIT ® leaching chambers number: 4- INFILTRATORS - ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: x ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 15insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 t Commonwealth of Massachusetts j�► - ,� Title 5 Official Inspection Form li`I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 SAINT C_A_TH_ERINE AVE Property Address BRENDA MO_RECRAFT Owner Owner's Name information is required for every HYANNIS MA 02601 12/8/2020 — _ page. City/Town 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.): 1-6X6 PIT WAS FOUND WITH 13" OF EFFLUENT AND 4-INFILTRATORS WITH 2.5' OF STONE FOUND DRY DURING INSPECTION 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.): 15insp 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 116 SAINT CATHERINE AVE Property Address BRENDA MORECRAFT Owner Owner's Name information is HYANNIS MA 02601 12/8/2020 , required for every 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.): i t5insp doc•rev 7/26)2015 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts ®Title 5 Official Inspection Form J� Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 116 SAINT CATHERINE AVE Property Address BRENDA MORECRAFT Owner Owner's Name information is required for every HYANNIS MA 02601 12/8/2020 _ __.�. page City/Town 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 c r r t5insp aoc•rev 712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 ; . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 116 SAINT CATHERINE AVE Lam.. 'Property Address B_RENDA MORECRAFT Owner Owner's Name information is required for every HYAN_NIS MA 02601 12/8/2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar r ® Shallow wells Estimated depth to high ground water: +10'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: TEST HOLE DATA PER PERC INFO ON PLAN ON FILE AT BOH Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form _ 1, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` V\ ate 116 SAINT CATHERINE AVE Property Address BRENDA MOREGRAFT Owner Owner's Name information is required for every HYANNIS MA 02601 12/8/2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Y 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 r For 15: Explanation of estimated depth to high groundwater included f t5insp.doc•rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 18 of 18 �/' .:�, .. ��5 �� , .�^ r � r r r l 3 �ed S M f � JJ � � 6 F? f O 0 1 r 0 0 i Y l v 1 7r I I J I .:I E • 1 TOWN OF BARNSTABLE LOCATION ll SEWAGE # VILLAGE0— ASSESSOR'S MAP LOT & INSTALLER'S NAME&PHONE NO. A - SEPTIC TANK CAPACITY LEACHING FACILITY: (type), (size) NO.OF BEDROOMS BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist 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) Furnished by --------.Feet --------------- p 610 _*O-- 7 R Z COMPLLA.NC�EDAT�E.- ? Distance Between the: 2: 9q,61 Co 0.0401 No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS ZIp�plication for �i!5pool *pgtem Cone;truction Permit Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) O Complete System Individual Components Location Address r Lot N�o� c 7°``� � Ow�r's Name, \_ sus and Ted.;o. �l �O.C.: Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Le 1 Z 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 Natu a of Repairs or Alterations(Answer when applicable) L/14 ke aro u Si'i�.4 S l� 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 i sued by this oard of H alth. Signe 4 Date Application Approved by Date Application Disapproved for the following reas Permit No. '� Date Issued -------------------- ----------- No. \� tV/ Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4Y / -PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS 0(pplication for i$ Og m�ar �pgte Congtruction Permit r Application for a Permit to Construct( )Repair( 4,9-rade( )Abandon( ) ❑Complete System ❑Individual Components Loc tion Address or Lot No B-/ ,� w\5 1, Ow is Name,Add ss and Tel.No. 19 Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. eO"�� 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 { Natu of Repairs or Alterations(Answer when applicable ' A9 i��Zev'3 &)l �/ S IOke-. Q f( x%Ark •t f s&�!ISL rX 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 i sued by this oard of He lth. Signe Date ` Application Approved by Date Application Disapproved for the following reasbi i Permit No._ ...� Date Issued -------------- --- -•- --------- l1 - THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance t `..,THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired ( W-Vpgraded( ) Abandoned( )by e d nr at �• e r`.,..e_X S e,v. has been constructed in accordance 'with the provisions of Title 5 and the for Disposal System Construction Permit No. dated Installer Designer ` A The issuance of this pe all no� e/ons rued as a guarantee that theWwl ill function aedesig 1 . Date I Inspector 0tr1, �1 / r V I 1 No. � — —� —------- ---------------------- Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS wlizpool *pztem Con.5truction Permit Permission is hereby granted to Construct( )Repair( grade( )Abandon( ) System located at_ ((6 C11T .-e a-'% y0.�h.S 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 q7ted 'thin three years of the date of pe t. / 4 rt � Date: Approved by //i --� r r 1/6/99 NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS) I, �o,,� �e�,-�L�.�S , hereby certify that the application for disposal works construction permit signed by me dated es- concerning the property located at l l6 Se Q.1 meets all of the following criteria: • e failed system is connected to a residential dwelling only. There are no commercial or business uses associated with the dwelling. • Fhe soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch. • t,.�ere are no wetlands within 100 feet of the proposed septic system h� • ire are no private wells within 150 feet of the proposed septic system •✓There is no increase in flow and/or change in use proposed There are no variances requested or needed. oy-The bottom of the proposed leaching facility will not be located less than five feet above the maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor method when applicable] •F If the S.A.S.will be located with 250 feet of any vegetated wetlands,the bottom of the proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted groundwater table elevation, Please complete the following: A) Top of Ground Surface Elevation(using GIS information) B) G.W.Elevation ' +the MAX-High G.W. Adjustment. _ DIFFERENCE BETWEEN A and B 2 t4 SIGNED DATE: lt-1 t 5 7 [Sketch proposed plan of system on back]. q:health folder.cert iI I 1 w� r a p i v y No._�! _`...3�2 Fss....��.: _ THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Appliration for Disposal Works Tuatgtrutrtuan Frrutit Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal System at: S C 6 uv't 4 !N rtq -1b 13.1�-toz ..----•--------------- .................I............................. ................................................ Location-Address or Lot No. -•- j� �_ -� --� - � `S •................................................... Owner Address s'�......e:�..... .�:��: `3��c -z -4�......CC �-t y�� -.............. Installer Address dType of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms................................ .....Expansion Attic ( ) Garbage Grinder ( ) U Other—T e of Building No. of persons............................ Showers — Cafeteria Q' Other fixtures -------------------------------• W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid-capacity............gallons Length................ Width---------------- Diameter................ Depth...... x Disposal Trench—No--------------------- Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area------------------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) ~" Percolation Test Results. Performed by........................................................................... Date........................................ 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........................ a ----•-••-••••---••-------------------•-•---•-••--•---•••---•--------------------•---......---------•......................................................... O Description of Soil------ --Z-------5 .V_S-•-------------- Z — �jr x --------- ------------------------ W ----••-----------------------••-----••--------------•--•-•-----------------------------...-•--•-••----•-•-•--••----••--------•--------•------••-••----------------.--•---------------------------------- U Nature of_Repairs or Alterations—Answer when applicable: ?'!`" :__' .. �(_.._.tw_.__ ��a ��a<...gh sF�i�t _ .....p l Ws eL - Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed . . ......----- - - -------------------------- ------ 1 S c1-O ..... � .... .. Application Approved BY Date V ------------------------- ------.,� Application Disapproved for the following reasons- -------------------------------------- ---------------------------------------.......-------------------------------------------- --------------------------------------- ------------------------------------------------------------- ------------------------------- ------ -------------------i---------- ----------- --------- ........................................ Hate Permit No. -------s�0.. ` 3 a'7------ Issued -----------------................................................ No..4 2-2 Fim...................... ` THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratinn for Disposal Works Tonstrnrtinn 11trmit Application is hereby made for a Permit to Construct ( ) or Repair ( )aan Individual Sewage Disposal System at: --I- C 6 P.fNt-�a IV M, 4o 13Awii ......M�.� -_- �` � ....__ Q h........................ - - ----------------------------------.............. Location-Address or. Lot No. •- �h� ._ ----------------------------------------- -------1A'"�'�`� _..---•----•--•--• ........................... er w a ,_ � nC, Address��.�� ...... ... - -�.. ...................... ..��....- a.....4 Installer Address QType of Building Size Lot............................Sq. feet U Dwelling)—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( ) aOther "Type of Building ............................ No. of persons---------------------- ---- Showers ( ) — Cafeteria ( ) QI Other fixtures ••------•-••-•---------••---•-•--•--•-•----•--- w Design Flow----;-----•----•---••--•----••----------••--gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—rLiquid capacity------------gallons Length---------------- Width.......--------- Diameter------.--------- Depth................ Disposal Trench`—No--------------------- Width-------------------- Total Length-------------------- Total leaching area_...................sq. ft. Seepage Pit No..... Diameter------------.-.--.-- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date------------------------'............... a ,.� Test Pit No. I....1-----------minutes per inch Depth of Test Pit.................... Depth to ground water......._=_--............. f4 Test Pit No. 2----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water-.--------..--------.--. -••------------••--••---------•-•-----••---------------------•-•-•----------------------------------......................................................... O Description of Soil....... -2-------5v .------------------z ��S----------sftll,� .............. x w U • Nature of Repairs or Alterations—Answer when applicablew`�-Pur .---.`! ._c:1�-•.--ya•----E-V—A*X A(------shsMm.._-_�rtip lwsT%0- ..bozo...Si :7 !t non.---ti'4c�'..---Q,Ct---------`-A t C------------------------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. Signed �^..... ------ ---------------- -------- 18 01-0---- Date ApplicationApproved By 3--------------------------------------------------------------------------- --------- � Date Application Disapproved for the following reasons: ---------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------- ------ --------------------------------------------------------------------------- ----------.......................... Date Permit No. ----------90--- 3—OL-7.................... Issued ------------------------------------------------------- ate------ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE S C�er#tf ratt of Tantpliatt r I THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( j by........... �� ------.t°� -----2N r.--------------------- -----------------------.-- ---------------------------------------------- ---rr -------------- Installer at .....- ..A t. = t'`�`' "I`a ............................--------- --------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of he State Environmental C,�ide as described in the application for Disposal Works Construction Permit No. ------..-.- ....'... .. ..7.. dated ....................................... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONS T GED AS A GUA NTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.......... --- ------. ---------------------------- ---- Inspector I THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH 32 TOWN OF BARNSTABLE' No. 7 7 t�............. FEE..__... ........ Disposal Yorks Tonofrn Lion UCrrntit Permission is hereby granted K\ \LE�! ro` s5 �= �� . to Construct ( ) or Repair (/C) an Individual Sewage Disposal System at No. . .........C' *`tt tw_Es........ .Q......................wY!�\ ........................................................... Street as shown on the application for Disposal Works Construction Permit No..X 32:2. Dated.......................................... ---------------------------- —------------------------------------••-........ - DATE_ -------------------------------- Board of Health FORM 36 508 HOBBS&WARREN.INC..PUBLISHERS