HomeMy WebLinkAbout0007 SURREY LANE - Health 7 Surrey Lane
Barnstable
A_298 - 047
IL
a��v
Commonwealth of Massachusetts .
Title 5 Official Inspection Form =
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Surrey Lane
Property Address §
Christian Pellon
TT.
Owner Owner's Name ,
information is Barnstable Ma 02630 10-1-18
required for every
page. City/Town State Zip Code Date of Inspection J4.
l.
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 aj 1 33 ti
on the computer, Brett Hickey
use only the tab
key to move your Name of Inspector
cursor-do not B&B Excavation
use the return Company Name
-
374 Route 130
Company Address.
Sandwich , Ma 02563 `
City/Town State Zip Code
r (508)477-0653 S113747
Telephone Number. License Number
B. Certification
I certify that: I am a DEP.approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ■❑ Passes
2. ❑ Conditionally Passes `
3. ❑ Needs Further Evaluation by the Local Approving Authority r -:
4. ❑ Fails
- Vu ,
Brett Hickey 10-1-18-
%'Dare:m+a+omxoa:us oavo
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the�Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
Please note: Thisrreport 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18
Commonwealth of Massachusetts
�n 1p Title 5 Official Inspection Form
/ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,
7 Surrey Lane `k
u Property Address
Christian Pellon 1
Owner Owner's Name
information is Barnstable Ma 02630 10-1-18
required for every
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:
The system was in working order at the time of inspection.
2) System Conditionally Passes:, t
❑ 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 Certificate6of
Compliance indicating that the tank is,less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below): .
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 18
f
cam, Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
7 Surrey Lane
Property Address
Christian Pellon
Owner Owner's Name
information is Barnstable Ma 02630' 10-1-18
required for every
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.7126=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts '
,p Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Surrey Lane
tJ
Property Address
Christian Pellon
Owner Owner's Name
information is Barnstable Ma' 02630 10-1-18
required for every
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary(cont.) µ
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply. ,
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or.
more from a private water supply well".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:..
Yes No
El 0 Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ❑ Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 18
c� Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Surrey Lane
Property Address
Christian Pellon
Owner Owner's Name
information is required for every Barnstable Ma 02630 10-1-18
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.),
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ El Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ " 0 Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ 0 Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ 0 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.
❑ E] Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ El Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.)
❑ ❑ The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
ElThe system fails. I have determined that one or more of the above failure
El 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 16,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section C.4.
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
❑ ❑ Y 9 (
Area—IWPA)or a mapped Zone II of a public water supply well
t5insp.doc-rev.7/2 612 0 1 8 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18
Commonwealth of Massachusetts
,p Title 5 Official Inspection Form
Ia Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Surrey Lane
V
Property Address
Christian Pellon
Owner Owner's Name
information is Barnstable Ma 02630 10-1-18
required for every
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 all inspections:
Yes No
Q ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ [D 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? "
❑ 0 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)
❑ El . Was the facility or dwelling inspected for signs of sewage back up? .
0 ❑ Was the site inspected for signs of break out?
El ❑ Were all system components, excluding the SAS, located on site?.
0 ❑ 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?
❑ 0 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:
0 ❑ Existing information. For example, a plan at the Board of Health.
ElDetermined in the field (if any of the failure criteria related to Part C is at issue
El approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface SewagL-Disposal System Form -Not for Voluntary Assessments
7 Surrey Lane
v
Property Address
Christian Pellon
Owner Owner's Name
information is Barnstable Ma 02630 10-1-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information ,
1. Residential Flow Conditions:
3 3
Number of bedrooms(design): Number of bedrooms(actual):
330/gpd
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): w
Description: 1"
Number of current residents:
Does residence have a garbage grinder? ❑ •Yes [j] No
Does residence have a water treatment`unit? ❑ Yes Q .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 0 'No
Seasonal use? ❑ Yes [E No
` See below
Water meter readings, if available(last 2 years usage(gpd)): '
Detail:
***2016-37,000gallons 2017-26,000gallons—
y
Sump pump? M Yes ❑ No
`•. .Aug-15-18
• Last date of occupancy: Date
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18
. t
Commonwealth of Massachusetts
Title 5 Official Inspection Form,
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Surrey Lane
v Property Address
Christian Pellon
Owner Owner's Name
information is Barnstable Ma 02630 10-1-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commerciallindustrial Flow Conditions:
NA
Type of Establishment:
Design flow(based on 310 CMR 15.203): ,
_ Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
` r
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? r ❑ Yes ❑ No
r
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe below):
3. Pumping Records: ,
Owner-last pumped 5 years ago
Source of information:
Was system pumped as part of the inspection? El Yes ❑■ No .
If yes, volume pumped: gallons p
How was quantity pumped determined?
Reason for pumping: r .
l5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts `
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u 7 Surrey Lane
Property Address
Christian Pellon
Owner Owner's Name
information is Barnstable Ma, 02630 10-1-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
1,
4. Type of System: a
0 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): 9
Approximate age of all components, date installed (if known)and source of information:
New SAS added to existing tank in 2006
Were sewage odors detected when arriving at the site? ❑ Yes No
5. Building Sewer(locate on site plan):
21
Depth below grade:
.. feet
Material of construction: F x
❑cast iron N 40 PVC ❑other(explain):
Town water
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
t5insp.doc•rev.726/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
f
Commonwealth of Massachusetts
r,
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Surrey Lane
Property Address
Christian Pellon
Owner Owners Name
information is Barnstable Ma 02630 10-1-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information-(cont.)
6. Septic Tank(locate on site plan): .
Depth below grade: feet
Material of construction:
W concrete ❑ metal ❑fiberglass •❑ polyethylene ❑other(explain)
F F,
If tank is metal, list age: years Y
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
1 .
Dimensions: 000gallons
Sludge depth:
29r,
Distance from top of sludge to bottom of outlet tee or baffle ,
3r,
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
13"
Distance from bottom of scum to bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage,etc.): A
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped-every two years for maintenance.
T •
t5insp.doc-rev.7/26/2016. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
c Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Surrey Lane
Property Address
Christian Pellon
Owner Owner's Name
information is Barnstable Ma 02630 10-1-18
required for every -
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan)
NA
Depth below grade: feet
Material of construction: .
❑concrete 0 metal ❑fiberglass ❑ polyethylene ❑other(explain):
e
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.):
. r
8. Tight or Holding Tank(tank must be.pumped at time of inspection) (locate on site plan):
NA
Depth below grade:
Material of construction: a
❑ concrete ❑ metal ❑fiberglass, ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
. gallons per day
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18
Commonwealth of Massachusetts
�s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Surrey Lane
Property Address
Christian Pellon
Owner Owner's Name
information is required for every Barnstable Ma 02630 10-1-18
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):
pry
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.):
The d-box was in working order at the time of inspection.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Surrey Lane
Property Address _
Christian Pelfon
Owner Owner's Name
information is Barnstable Ma 02630 10-1-18
required for every
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 0 No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
NA
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
(5)hi cap infiltrators
0 leaching trenches number, length;
❑ leaching fields number, dimensions:
❑ overflow cesspool number: _
❑ innovative/alternative system
- " Type/name of technology:
t5insp.doc•rev.7/26/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
Commonwealth of Massachusetts
�n Title 5 Official Inspection Form
li Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Surrey Lane
u
Property Address
Christian Pellon
Owner Owner's Name
information is Barnstable Ma 02630 10-1-18
required for every
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.):
The leaching was in working order and was dry with no high staining at time of inspection.
12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
NA
Number and configuration „
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow _ ❑ Yes ❑ No
Comments(note condition of soil, signs of-hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
j Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Surrey Lane
Property Address
Christian Pellon
Owner Owner's Name
information is Barnstable Ma 02630 10-1-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.). -
13. Privy(locate on site plan): -
NA
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
r
i
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -.Not for Voluntary Assessments
7 Surrey Lane ~
u Property Address
Christian Pellon
Owner Owner's Name
information is Barnstable Ma 02630 10-1-18
required for every
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:
FM hand-sketch in the area below
❑ drawing attached separately
t
Asbuilt Ground water
W y 1V
.V_
Driveway
36„
Garage I 52"
lii cap.infitrators
A , B
Deck
�>144'
>92"
IT -1 1 .1 IJ
Al-59' B1.23'
A2.64' 52.17'
A3.52' 83.38' ,
Ground water
t5insp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
� I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�* 6% 7 Surrey Lane
L
Property Address 4
Christian Pellon
Owner Owner's Name `
information is Barnstable Ma 02630 10-1-18
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
Check Slope '
0 Surface water '
❑■ Check cellar
❑E Shallow wells
•Estimated depth to high ground water: .,No GW @ 144"feet
Please indicate all methods used to determine the high ground water elevation: r .
Obtained from system design plans on record
. 4=4-06
If checked, date of design plan reviewed: pate
❑ 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: ;
A plan on file with the Board of Health was used.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Surrey Lane
Property Address
Christian Pellon
Owner Owner's Name
information is Barnstable Ma 02630 10-1-18
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
p■ 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
F■ D. System Information:
For 8: Tight/Holding Tank—Pumping contract attached ,
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached.
For 15: Explanation of estimated depth to high groundwater included
' r ,
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
r
TOWN OF BARNSTABLE
LOCATION 7 Sa &Y SEWAGE# 6'0
VILLAGE ASSESSOR'S MAP&PARCEL/V P t
INSTALLERS NAME&PHONE NO.
SEPTIC TANK CAPACITY M6
LEACHING FACILITY:(type) a- V j:/j0,Q ize)
NO. OF BEDROOMS
OWNER
PERMIT DATE: L5 �� 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) 4 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
FURNISHED BY
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Commonwealth of Massachusetts
Title 5 Official Inspection Forrri
` ._. Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
7 Surrey Ln
Property Address
Eugene Cabana Trust
Owner Owner's Name
information is
required for every .Barnstable MA 02603 12-19-12-.
page. Citylrown 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_
ImporiWhen A. General Information
filling out forms `\``���tN►OF►nr�y,����;
on 1he computer,
use only the tab key to move your Inspector:eCtOf: (� (n u � ) _� 9
•'- �.
curso d not of James D. Sears _�. JAMES ?m
use the return Name of Inspector = A Kcj
key. r a;
Capewide Enterprises, LLCCompany Name
c o.
153 Commercial Street
Company Address
Mashpee MA 02649
Cityrrown state. Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
I certify that 1 have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection.The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system.
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
- 12-19-12 t
pector's Slgnalure Date
The system inspector shall submit a copy of this inspection report to the Approving Auttro ity(B_Trd
of Health or DEP}within 30 days of completing this inspection. If the system i 0a sharedtystemroror
has a design flow of 10,000 gpd or greater, the inspector and the system owne(shall submit the-
report to the appropriate regional office of the DEP. The original should be serif 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.
f5ins, vto Tide s ofidal l p on Form:subsurmm sewage nispossi System•Page 1 or 17
Dec 20.12 05:08p p.2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Surrey Ln.
Property Address
Eugene Cabana Trust
Owner Owner's Name
information is required for every Barnstable MA 02603 12-19-12
page. Citylrown State Zip Code Date of Inspection
B. Certification (cost.)
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:
B) System Conditionally Passes:
❑ one or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes","no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•11110 Tree 5 Official Wtspeulan Form:Subsurface Sewage Disposal System-Page 2 0117
Dec 20 12 05:08p p.3
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Surrey Ln.
Property Address
Eugene Cabana Trust
Owner Owner's Name
information is Barnstable MA 02603 12-19-12
required for every
page. Citylrown state Zip Code Date of inspection
B. Certification (cont.)
B) System Conditionally Passes(cont):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced [] Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment
1. System will pass unless Board of Health determines in accordance with 310 CMR
M303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•11f10 Title 5 Official kmspeaion Form:Subsurface Sewage Disposal system-Page 3 of 17
Dec 201205:09p p.4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
r( 7 Surrey Ln.
Property Address
Eugene Cabana Trust
Owner Owner's Name
information is
required or every
Barnstable MA 02603 12-19-12
f
page. Cityrrown state Zip Code Date of Inspection
B. Certification (cunt.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or 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
❑ [R Liquid depth in del is less than 6"below invert or available volume is less
than '/2 day flow 4,�W C1111V a
tsins-1 T/10 Title 5 Mist inspection Form Submdace Sewage Disposal System-Page 4 of 17
Dec 2012 05:09p p.5
Commonwealth of Massachusetts
-, Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Surrey Ln.
Property Address
Eugene Cabana Trust
Owner Owner's Name
information is Barnstable MA 02603 12-19-12
required for every ,
page, Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
El 0 Required pumping more than 4 times in the last year NOT due to clogged o
e9 P P 9 tt e Y 99 r
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system_is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
Sins-11110 t Tihe 5 OlBaal Inspection Form:Subsurface Sewage Disposal System Page 5 of 17
Dec 2012 05:09p p.6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Surrey Ln.
Property Address
Eugene Cabana Trust
Owner Owner's Name
information is Barnstable MA 02603 12-19-12
required for every
page. citylrown State Zip Code Date of Inspection
C. Checklist
Check if the following have u been done. You must indicate yesn u or nos as to each of the following.•
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (if they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs.of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions,depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)`[310 CMR 15.302(5)]
D.- System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 16.203(for example: 110 gpd x#of bedrooms): 330
t51na•11l10 Tdle 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 6 of 17
Dec 20 12 05:10p p.7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Surrey Ln
Property Address
Eugene Cabana Trust
Owner Owner's Name
information is Barnstable MA 02603 12-19-12
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal precast tank D Box and 5 high cap infiltator
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes 0 No
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)); 2011-11,000GaI2012-5,000 Gai's
Detail:
Sump pump? Yes ❑ No
NA
Last date of occupancy: Date
Commerci!allindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-11110 Title 5 Official Inspection Form:Subsurfaos Sewage Disposal System-Page 7 of 17
Dec 2012 05:10p p.8
CommonweaM of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Surrey Ln.
Property Address
Eugene Cabana Trust
Owner Owner's Name
information is required for every Barnstable MA 02603 • 12-19-12
page_ City/rown State Zip Code Dale of Inspection
D. System Information (cunt.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NO
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-1111 U Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Dec 20 12 05:10p p.9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
7 Surrey Ln.
Property Address
Eugene Cabana Trust
Owner Owner's Name
information is required for every Barnstable MA 02603 12-19-12
page. Citylrown State Zip Code Date of Inspedion
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
2006 Permit# 2006 - 244 D Box and leaching
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 22-
feet
Material of construction:
❑ cast iron ®40 PVC ❑other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints,venting, evidence of leakage, etc.):
Pipeing is 4" PVC SCH 40
Septic Tank(locate on site plan):
14"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 Gal Precast
Sludge depth:
t5ins•11HU TPJ9 5 OfhCJe1 ftpeMton Form Subsurface Sewage Di5p0521 System•Page 9 of 17
Dec 20 12 05:11 p p.10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Surrey Ln,
Property Address
Eugene Cabana Trust
Owner Owner's Name
information is required for every Barnstable MA 02603 12-19-12
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cons_)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness 2"
Distance from top of scum to top of outlet tee or baffle 8.1
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? Asbuilt-Plan-Tape
Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc_):
Tank and covers at 14" below grade w fin and outlet tee's. No sign of leakage or overloading.
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
ESins 11f10 Title 5 Official Inspection Form.Subsirface Sewage Disposal System•Page 10 or 17
Dec 20.12 05:11 p p.11
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
7 Surrey Ln.
Property Address
Eugene Cabana Trust
Owner Owner's Name
information is required for every Barnstable MA 02603 12-19-12
page. City/Town State Zip Code Date of Inspection
D. System Information (cons)
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 bolding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass []polyethylene ❑other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Dace
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required)_ Is copy attached? ❑ Yes ❑ No
tSins.11110 Title 5 Offieal Inspection Form:SubsMsce Sewage Oisposat Systam•Page 11 ct 17
Dec 20 12 05:11 p p.12
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Surrey Ln.
Property Address
Eugene Cabana Trust
Owner Owner's Name
information is required for every Barnstable MA 02603 12-19-12
page. CityRown state Lp Code Date of Inspection
D. System Information (cons.)
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D Box is 16"x16"-W below grade w/10" cement cover at 3". Box is clean and solid wl one line out.
No sign of over loading or solid carry over.
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.):
Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
15ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
L
Dec 20 12 05:12p p.13
Commonwealth of Massachusetts
u,p-
, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Surrey Ln.
Prop"Address
Eugene Cabana Trust
Owner Owners Name
requiratifo is Barnstable MA 02603 12-19-12
required for every
page. CityrFown state Zip Code Date of Inspection
D: System Information (Cont.)
Type:
❑ leaching pits number:
® leaching chambers number. 5
❑ leaching galleries number.
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovativefaltemative system
Typetname of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching is five high cap infiltrators. Chambers are 2'below grade w!3 1/2'stone. Camera -
prob and T.H. Chambers are clean and dry. No sign of over loading or solid carry over.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan).-
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins 11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Dec 20 12 05:12p p.14
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Surrey Ln.
Property Address
Eugene Cabana Trust
Owner Owners Name
information is required for every Barnstable MA 02603 12-19-12
page. Cityrrown J state Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding,.condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
L
Dec 20 12 05:12p p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
7 Surrey Ln.
Property Address
Eugene Cabana Trust
Owner Owner's Name
information is required for every gamstable MA 02603 12-19-12
page. Cityffown State Zip Code Date of Inspection
D. System Information (cunt.)
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
Eck"
c v
d4 tv�C
F-1 I I I
Z 13
5-
f5ins•11010 Tills 5 Olfidal Inspectfan Farm Subsurfoos Sewage Disposal System-Page 15 of 17
Dec 20 12 05:13p p.16
\ CommonutreaM of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
7 Surrey Ln.
Property Address
Eugene Cabana Trust
Owner Owner's Name
information is required for every Barnstable MA 02603 12-19-12
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)'
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells' N 0
Estimated depth to�igh ground water: 12'
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked,date of design plan reviewed: 4-14-06
Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with focal 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:
T.H. on Design plan 4-14-06. No G.W.at 12% Bottom of leaching 3'Below grade 9' above T.H.
depth.
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ns-11110 TIHe 5 official Inspection Form Subsurface Sewage Disposal System-Page 16 of 17
Dec 201:2 05:13p p,17
M
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Foam -Not for Voluntary Assessments
7 Surrey Ln.
Property Address
Eugene Cabana Trust
Owner Owners Name
information is required for every Bamstable Mal 02603 12-19-12
page. C41'rown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
Minn-11110 Tine 5 Official Inspection Forth:Subsw face Sewage Disposal System•Page 17 of 17
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No. . -OL4q Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Application for �h5pogar �pttem Con.5truction Permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑ Complete System ❑Individual Components
Location Address or Lot No. 7 Svc:st L4 Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel Q 4_1 � Uteh✓) t&_�l
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
c ,
Type of Buil ing:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3�,� gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ('1s7t52 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) G���a,,gC74
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maint ce of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Env' mental C de d not to place the system in operation until a Certificate of
Compliance has been issued by this Board of He
Signed Date
Application Approved by Date
-Application Disapproved by: Date
for the following reasons
Permit No.C-}-0a6 " °) L/ l-1 Date Issued
No. 1 Feed
THE COMMONWEALTH'OF,MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS YeS
ZippYication for Migo,5a1 �&p#gtem Con, itruction Permit
Application fora Permit to Construct O Repair( ') Upgrade.( )"Abandon Complete System 0 Individual Components
tLocaticn Address or Lot N3. SOK.(L{ilq, •Owner's Name,Address,and Tel.No.
d Ct�►M�, a ( `�
Assessor's Map/Parcel, act
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building: ,r
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) a gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank c9t0t::9 Type of S.A.S.
Description of Soil
r
Nature oQRepairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maint�riance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Eir nmental de and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Heal'
Signed Date
Application Approved by Date 5
Application Disapproved by: Date
for the following reasons
Permit No. Date Z� Date Issued 30 6
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIF ;that the On-s' e'Sepage Disposal System Constructed ( ) Repaired ( Upgraded ( )
��- Abandoned( )by o K�� r
at SU/�Q�i has been constructed in accordance
with the provisions of Ti le 5 and the for Disposal System Construction Permit No. G "c7 �V 9 dated ��✓
Installer F Design
#bedrooms 13 Approved design flow 1330 gpd
The issuance of this permit shall q6t be/coonstrued as a guarantee that the system will fu ctiton-as designed.
kr Inspector \ '"'�---- r
Date �'' 't
No.c;co(o , Xq q Fee
-- - THE COMMONWEALTH OF MASSACHUSETTS '
PUBLIC HEALTH DIVISION—BARNSTABLE,MASSACHUSETTS
Migogal �&p5tem ���truction Permit
Permission is hereby granted to Construct ( ) Repair ( ) Upgrade ( ) Abandon ( )
System located at (J��
J►m ems `
�a l
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty
to comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date TtY is ILL
Date 5/3CD l6 Approved by—_.
M
Town of Barnstable
OFtHE 1pk, Regulatory Services
�O
Thomas F. Geiler, Director
• BARNSTABLE.
9�A � Public Health Division
rEDMA�a Thomas McKean, Director
200 Main Street,Hyannis,MA 02601
Office: 508-862-4644 Fax: 508-790-6304
Installer& Designer Certification Form
Date: U -
Designer: Shay Environmental Services, Inc. Installer: n
Address: P.O. Box 627 Address: 14- , to A i,.9
East Falmouth, MA 02536 }�
On_ ��� ` ®� p� C1 Q ��a +Z was issued a permit to install a
(date) (install
septic system at ' 30¢2E LA. M�\based on a design drawn by
(address)
Shay Environmental Services, Inc. dated ,1 _
(designer)
I 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 Regulations. Plan revision or
certified as-built by ner to follow.
SN OF MASS
410 o� CARMEN
nstaller's 8i nature) E.
No. 1181
0
�SofsTS
P
(Designer's Signature) (Affix Desa p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:Health/Septic/Designer Certification Form
a
9/16/03
Notice! This Form Is To Be Used For the Repair Of.Failed
Septic Systems. Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I, (RIV erJ S%4AY hereby certify that the engineered plan signed by me
dated of ,concerning the property located at
nS�Cc��le meets all of the
following criteria:
• This failed system is.connected to a residential dwelling only,...There.are no.commercial or
business.uses associated with the.dwelling.
• The.soil is classified as.CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or may conduct deep
test holes and percolation tests at the site without a health agent present.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The.bottom of the proposed•leaching facility will be located no less than five feet above the
maximum adjusted groundwater table-elevation. [Adjust the groundwater table using the.
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) _ 2 Q ,p o
B) G.W-. Elevation 3 O +adjustment for high G.W.Z= 3 2 , 00
DIFFERENCE BETWEEN A and B 2 6 •0O
SIGNFD : Q DATE: - Oko
NOTICE
Based upon the above information; a repair permit,will be issued for bedrooms
maximum.. No additional bedrooms are authorized in the future without engineered septic system
plans.
gASeptic\percexemp.doc
LOCATION L SEWAGE PERMIT NO.
NI.LLAGE
Q at\j1 c (N i�,L� - o
I N S T A LLER'S NAME & ADDRESS `
X cc ► 5 42)(L6
B U I L DE R OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIAN-CE ISSUED //ME
0
�ti
No... /-3S-e ......... .....
I THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
Gu. .........OF.............a/� ?.tl.S-TA ./:. .................
ep �,� liratilan for Di£ wi al Works Tomitrurfila t antic
Application is hereby made for a Permit to Construct (xt or Repair ( ) an Individual Sewage Disposal
System at:
Location-td&kess ," or Lot No.
. .. ! .. .............•......... .......................... ............................................................
a
. ner Address
............... r .�...e...--•---..................•-
•...........................•.. � ..._..
Installer Address
U Type of Building Size Lot--- ...Sq. feet
Dwelling—No. of Bedrooms........2...............................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers — Cafeteria
a yP g P ( ) ( )
Otherfixtures ......................-................................................................................................................................
W Design Flow............. .....................gallons per person per day. Total daily flow...........ew_.....................gallons.
WSeptic Tank—Liquid capacity./AA0gallons LengthA9'Gz'!.. Width._4./t'P"Diameter________________ Depth...S.�.4"
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......../......... Diameter... G.�._.._.. Depth below inlet....... _.._.._... Total leaching area._2 2...sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by._.......E�_./_.0.`ft fl t�l....4 ......._. Date.....�0-,!/2,1��.......__.
�l "i
4 Test Pit No. 1...e .._._minutes per inch Depth of Test Pit... ...... Depth to ground water------------------------
0-4
(s, Test Pit No. 2__G.2...minutes per inch Depth of Test ... Depth to ground water......................
W' ----------------------------------------•------:.........------......----•--•---•-•-------......----........................................................
0 Description of :'2p...T.uP,,.s�. i '�/GL------•---# - -� TO/�sll �._F..I.�L---•-----
x
V =....�P`__.2.4::-1DB /��.v -Sr`�! �' s! `!�--------36... .7�_`_.C.. S'
W ............................................ 4G-..etHlze- '�O .5.9.V-0---------- C`-='-p"y- H 4ZX........
UNature of Repairs or Alterations—Answer when applicable................................................................................................
--------•-------------•-----.....-•--------•-----------------•----------------••--•-----•---........------------•--•-----------••-------••-----------•----------------------------------------......---.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of A.iTlE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compl. ce has n i s d by t board of alt .
-•------------------------------•------••..---
D
ApplicationApproved By..................................Q::.". ,�........................................... ...........
/ Date
Application Disapproved for the f ollo�" on :------•-••-------•-•----••--------------------• ...........................................................
............................................................. /.:...
Date
Permit No:.......: =` .. Issued.......................................................
•-
Date
'1
No... �... O Fim............._............
_
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T .:.f�.........OF.............. . � s 9%� G c
...... . . ..........................:.:.................
Appliration for Uispuiittl Wurkii Tonotrudiun lirrutit
Application is hereby made for a Permit to Construct ( x) or Repair ( ) an Individual Sewage Disposal
System at:
................_:. ,.�iz.fs Y.: ..G. :.%: ..... ........_..... ...• ------------------------ -------
...............
... .....
Location, ....or Lot No.
Address
cti.:...A............................•..•... --•---........-•----..........-----•...............................
Installer Address
QType of Building Size Lot.... _vo...! --2..Sq. feet
U Dwelling—No. of Bedrooms.........ja..............................Expansion Attic ( ) Garbage Grinder04 ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
a Other fixtures •---.---.-.--•-.••-----•.-..---..
W Design Flow..............1-1.G.'...._................gallons per person per day. Total daily flow............ .....................gallons.
WSeptic Tank—Liquid ca.pacity_Gt::_::zgallons Length...-.-.._....... Width..:::.!::....Diameter................ Depth....a.......4.
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No---------/......... Diameter.... .......... Depth below inlet.......(.......... Total leaching area...::<f.l...sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by........-K M... 1_ ...... ........ Date......6V ...............
al Test Pit No. 1...4.e.....minutes per inch Depth of Test Pit....ef5..!t...... Depth to ground water........................
Test Pit No. 2...G.. ...minutes per inch Depth of Test Pit...l.S._-F....... Depth to ground water........................
.....----•-----•------•-----•---------------------•--..................-----..........•-----......7--•--------•---•------------•--------------•---------•-•-
O Description of Soil--. .......... - r.
V _... ............... _.. `�---•----------_----- .. ..... '�....i.... ...'-..........z..... -7�.....G:.. _[--5- •.-••---•-••------------
W rn.r C
UNature of Repairs or Alterations—Answer when applicable...............................................................................................
..•---•••-•-••------•-•-----••------•------••••••••---•••-•-•-•..................•••.....---------••-••---........••---••---.......-••-••-•--.........•--••-••-------.........._•-•-•-•.......-•-•••---.
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of T?T T-:-: 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has or
i d by tht board of� .lt
Signe :. i. Q'y f9 . 4 ..
Application Approved By................................ .............................. ------.---
Date
Application Disapproved for the follo * 9 ea�••----•••-•••-••--•----•-•••-•---------•---•••---•................•---.._..............._-••---------•--.......
...--•-----------------------•---•-...........•---•-••-•---...-•-•• f ...........................................................................................................................
Date
PermitNo--------------------------------------------------------- Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOAR?�OF HEAL, H�
......................O �
Trrtif iratr of Toutpliatta
THI TI That the Individual Sewage Disposal System constructed ( or Repaired ( )
by........ .._4------------------------ - -- ..................... --- --- ....... . ....---......--------------•-•-..........------........•.......
at...... -!--1-• .................. ...........
has been installed in accordance with the rov' ions of TITLE 5 of The State Sanitary Cod as d ri ed in the
application for Disposal Works Constructi ermit .............. dated .-.--_.---. --.
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A UARANTEE THAT THE
SYSTEM WILL FUNCTION SAT/lSFA hhTOyRY.
DATE........................................8- -1 ..11 ............... Inspector------- .. ..SJ _.................----------.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARDepF HEA
NtY1 .......................OF.. ...11,1.�:x:e..r FE
...3�f�. r iy_.o..................
too _ ton Vern it
Permission itliereby granted.... . -' f
to Construct g�Rejr�( ) an I victual Sewag D sal Syst
atNo.--------- .....__ .. - .. �-�. - =•,.. .............
:" street /G
as shown on the application for Disposal Work C struction Permit 4..._ 3•.0-•. Dated. ... s.... .........
Bdt ealth
DATE........................:. ................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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LEGEND '"`'; � .
EXIST.I:NG SPOT .ELEVATIONS O4 f- ;j. , " `
EXISTING CONTOUR ='— 0 = =
FINISHED SPOT ELEVATIONS
FINISHEDw conlTouR o PROPOSED PLOT PLAN °
z APPROVEDs BOARD OF HEALTH " "' ., t,` }
,., , I3Aa14/srl3� , MAS$.- ,f
+ �.
,< DATE AGENT LoT ;34 �Sulele l�9/I
CERTIFY_ THAT THE PROPOSED R. j O'HEARN, INC..9 S, RS "w�,
BUILDING .. SHOWN ON THIS PLAN 1348 ROUTE 134
' EAST DENNIS MASS.
CONFORMS, . T, THE ZONING LAWS
:pF . MASS.. DATE : G/24119/ SCALE: 2/ —30/
r. JOB N0. P/—//103 CLIENT:' GiA350
DATE REGISTERED LAND SURVEYOR DR. BY �✓F SHEET�.L_ OF Z
. .
..; -- __-.1�1
_.- ,...-__ , _—' _____—