HomeMy WebLinkAbout0353 GREEN DUNES DRIVE - Health 353 GREEN DUNES'DRV. s '
Or
CENTER VILLE EA = —
„
UPC12534 R
WAITIM, YN �►�'
i
No. � ®�
� 31Y Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
ftplitation for Disposal 6pstem Construttion Permit
Application for a Permit to Construct( ) Repair('A Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No.35 3 CAN 1Jv►J t s DQIUE Owner's Name,Address,an Tel.No.
CC-_.J T�rc.L,� KCv t'i .2i'1404P _
Assessor's Map/Parcel a�� t3r6 PD f3 O 7 `, 6r r_
Installer's Name,Address,alld Tel.No. Ch7— S927 7 Designer's Name,Address,and Tel.No.
CeA®6la>tDtb EtvQ_tS� Z-[.L r
Type of Building:
Dwelling No.of Bedrooms Lot Size a-a-3 ' sq.ft. Garbage Grinder( )
Other Type of Building R GSL 0 a)T(PrL. No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
PGTL-ACL H-OLOD-e>O C
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 Certificate of
Compliance has been issued by this Board of Health.
Date it- IA-(
Application Approved C7SI
Date l
Application Disapproved by Date
for the following reasons
Permit No. t 3 — 14 Date Issued 11 1
��
j _ _ D�J tii
r Fee
No. !ll��� T Entered in computer:
THE COMMONWEALTH OF MASSACHUSETTS
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
2pplitation for Disposal *pstrm Construction permit
.Application for a Permit to Construct( ) Repair N Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No.35 3 G—Rty--N Dv O ES DQ'Vc Owner's Name,Address,and Tel.No.
KEv�N (�.4Rrzon/
Assessor's Map/Parcel a,c� p 7 S L/&'-- Hy 4&)U SPC*-
Installer's Name,Address,and Tel.No.s0fr 417-i5g77 Designer's Name,Address,and Tel.No.
VIA
Type of Building:
Dwelling No.of Bedrooms Lot Size 3 -' sq.ft. Garbage Grinder( )
Other Type of Building 'Ro�( -r(AL. No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 Certificate of
Compliance has been issued by this Board of Health.
i Date ( `
Application Approved Date \) 1
Application Disapproved`by Date
for the following reasons
Permit No. 3' Date Issued 1 1>
TH E COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( X) Upgraded( )
Abandoned( )by (�APFLQJ r DG 66J7M"4 e L,G-
at 3 53 Kj bouE 1Q. cb,�'�ji�V(U6 has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No "" / dated
Installer !�A.po y ng 6L) 19 P4J %f LL-C- Designer �J A
#bedrooms Approved design flow ,a f gpd
p� ,.
The issuance of this permit sla/11 not/�b�ej/co�njstrue a guarantee that the system willtfiiricti/onj?ast,dejsigned / "ell / #'
Date f / lay Inspector IYl r'�f i(� A) 4l � '!
--------------------------- ------ ---------------------. ------ _ --.----------------------
� -
No. —� 1 Fee /6) U
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS
disposal *pstem Construction 3permit
Permission is hereby granted to Construct( ) Repair(X) Upgrade( ) Abandon( )
System located at .353 CkOARE0 Dt )ue-5 DA1 vc CEVTeQU[CL.C57
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
i Title 5 and the following local provisions or special conditions.
Provided:Construction ust be c mpleted within three years of the date of th' ,n
pe'mit`�
Date 1 ApproZd by
i
TOWN OF BARNSSTABLE
LOCATIO v ��,5� QIWtJ SEWAGE #
a'LLA.vE ASSESSOR'S MAP & LOT AlA
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY C VOr
LEACHIlvG FACILITY: (type) o� (size)T�
NO.OF BEDROOMS
BUILDER OR OWNER
PeF�qDATE: C0M_PLIANCE DATE:
Separation Distance Between the:
Maximum F Adjusted Groundw ccc
� aterTable
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) 06Feet
Edge of We and and Leaching Facility(If any wetlands exist � � � �
within 3 feet of leaching facility) _ P-'jA Fee_
Furnished by �I �•
� 3S3
t�
A- 77r t31 -3�°« h z ® �
k3- 13 63
�/.,3 .�pry/
;:.
C:ornrnonwealth of Massachusetts;
r ,;
Tine 5: ffic� 1 lnS : dog r
_ — Subsurface Sowage 0rspQsal System Form No#for Uodunt; ry Assessments
353 Green Dunes Dnve
. Property PCiidress .
�I /.....:1I.I,--.1...I.:.::I.I�.:I1�..--I.-:1�1.�;::..:--I.I-1-..:�.1:II::-.-..�'1....-III��1I.I::I--:-1.......I.I.�I.....-I.I.-:,.�I..::..1 I,1-.1:...:..�.:���.:.-::..:.:II.I:...:-II-:.�....I.:..:-I.:':.-.�:I-.I1.-..III:...��..,.II--I...::--.II�...1.I:::.:...I::.-�.I:-1�-.I..1.I.,::..I.�....�..I,1....-....1:�11i:II::::-�...11.:.1--.:.:I.:..�:.::-...�-I.1.�.-:�.I:II.,.1:::-:..I1.:..1I::.,,:.,.....III.1.....I-.I---I-......-.q.-..�:::-.-.:.."..I....I.....::-,.i......I1,I.II...:::.:I:.::wI.II4..�I�.:1�.1�..p.�---.::I:....II:.:.;..1..:�..:.:.I..-::�:;1-1-...I-..1I..:::-...1.,..*.,:*:-.I--..I..:..::.�:--:-:1 1 I.J1-::.�.�.1:....I,:.-Ip---.I.�1..,'�,.:I..-:.1.-:�1::I.p-...I::;i�1..�...--..,:I1.-..,.:.I....-.�:.I.:-..-"!,;-.-,..�
HARFtO:N,,KEVItd P&,$R01NN, K.:...--:..-�,1��......-...1.:.�I.:...�-.:..-.::-...;.-::::::.-.:1...1.,:,1.j-.1..Ii.:..-I1-.:.-,...:.-.;:.::.:..:-:-:::*Ip:,.-�,-�..-...,..II'-.:,I.-......:�:-..,1..::..:�.�..:-:.:.*�::.:�
fMBERL EE A
Owner Owner s Name __
:-..:..-......I-....:::.I:.-1:..-...-...:..,.II,1I.:�I�.�....,.:I..''--::.-:--1,�'..I.:.:.'1--:�:-�:..:....-::.....I.:p:........-:.:1,...-1-.*....-..--.-.I11
.1::...,...-.i1..I-,::-.1...-.II'.�::.-;--IIIII,1:..-.-I��:.�..�..:.-,1:I::..,.I-...I,1I.I.::..I.�I.--l:.:.:..:.-.:-::.q:..:.-...-;:-..:-.-1-....�-�.:;..,:,I.I-
,--.�.�..-.-::m..-..�7.�'�.-.:-:-.-.-:.�.:::.i:..:I.i:-:::.:.::.,:*�d::.-:-.�:1-:.I;.m..-,...�:::p:1.-�-.:-�1p.-:�:.::.:...I.--..o:-.,I..71�.�1.�.::�::.I..:.!.._I1N.-::-.-:b:..-.�..,*.V--:I-.-'-I I 1::..:::P..1I f.:.:.:�1:...'.::.:.*-1�_-.....,---':..::.4:..,.,:::-....:-1.,-.1:::::.....-;.�-7..*..1..I..::.��..I..-_-:..1::..I...:::::.:::-.::.....:....:....-:.:.,;:,q::I..:d.:,.-.-tI.........I:*.::.::::,1-...::::...:....:..1:....I..-..I11
I I.::-..-.::.:..-..-,jI:..m...-:......I.-.F.��.:-:-.,....�I
'...:..-.:*.:...:::::...::..,.:-.�:.I:�:1 I;.:-1�..:.::..-...:::::::...:::.I1...--...:-.*::..�.'.::.,..*...::,.1--.1::-.:I:.:�.:,....i::,.:-.::::.:.::.-�::.....:..:..��:.:1:.--..:.�:1I.�-._.-.....:.:-.::,.-..::--..:::I-.1...::�.:.:.�
-I.:�-..-...:1.::.....:.:.'...::'.��::1.-,.I.1..:.�,m1:..*.:*--.:::�:.:.....::.1.�..::..:I..::�.:...:..-.!:.:,I.,-':..::.::....,1,1...::.q:..'..:::.::..:I:-.:.*..�.:.:::.I..-,..11-..:I:-:I...-.::-:....:,.:.:..1:.-'F.I...I.II....::.,.......::.:.w.-;:::..1:..:.:..�::,o..:..�.�::,�...::.-.b..-::.:.�...I.....:-:.-..�.:,.:,..-.�:F..m...�-:..:-.:-I.I..-:�....I...I.:..:..I I.I
:..I:�:��--.m.:*.m...:.-.:.........:.::.:I-.-...*:..,.II�..�-*I�*...--
".;..-.,�---:..,-..,:.:�...-,.:,...�:.I..II...�....-.:1.-!.�..--.:-..:,.-.
:,.I.._.,�I....-.1;.-1.!---*:..-.:...�.....,..:.-I.:-...:--.......-.....-�:�-::....I::-:..:...1:.�
-....�:..::.:::::..:-.,1-:.'::...:..-.I.-,-,.1::'-.,—.--�--..-::.--I-d..::.,.,:...�.....:.1.I.-..I 1.--.:*::.:-...,--,I�.:;.F,:,.-..-1:.-::..:.r
--,.1:.�--
1-...:.:-..:4-.i.:..:I,_.-:-.1-.::-..1.--..:::..-:-.:d..,�,.,.-:.1:-.,-1:.:-',..4.�.-.:-
1.:-.'-:..1:....--..::..-::...:,::--.:::1....�.-..:....-1.:.:-.,%:-".:,..,.,I..:..1:I-�----,.-I.::..:-,-...:.:I-�-.,....1.-:-.',-�.
.I.:--
-..".:-:-.:.::.:-..0....:::-.-:.:.-�...:..::-1.:,:.-_:-:1-.-�I-.I.�I1...."I:-.-::�,-.-�...-..:-�-1..,-I..1--.
:�-:-.i....1-I..-.-,-:.:.1:,.I.....-,I...1..,..i.-..-..
-.::..1:,:1�I......1.I�,-:.--I�:.,.-..1.-...-:I1 1_-...:--.:..-.,.,.-..:.-�.1�,:.:-.-..1 II.:.:--d..�:-1.-*.,...1..�..
,.-..::--:1::.I�:.1.--,...--"D:.:-I.
....:--..I 1..�....:.p-.:,-..:�1I..�.1...1.:.,"..-I,�:..1-...�:I.II-.-I:.-�-.�:.—.:---I.
....:.:,..---,�_—.-:...:.p::.R:..-:..1�1I....1...1.::.I:...-.::.I..:.l.:....::.:m.::,.11:..
...I I...I..-�..I--.:.::,..:::�.;..:1
..'...._.-.1..:.!.-..:::q'.:...I...:.:.-I.�...I.1.*:.1..11.:!--.:......:'p.1.:.::..-.:.,
I-..I..I::..I.1..:.I:.d--..:..-.
..::11....--.....1I:1.--:::.-*.�..:l..q.:::"I
-:....,;....':qI.:::.:�::.,.:..:....:p.
-.II..:.-:.1:...:'...::p:..,-F..4:-:.:.-..,�I I...,I..�.-....�.::-....::....-..:-:.::.:�.'..1.�........:.:::.-.-..:m-..:..F�::-.:1.:::.
....::.i.:-......:.I.:p::::*:.-.:w�:::..:--...,..-:..."..
.�...:.',-�.'....'.�..I..::..::.�:::.:.:....:p'...'...-......-....-.:.,::-.::�:::..F-:::...:::,,1 1...,;..�.:-I.:...�-:::..,;'::*�:::::F.:.
.::...::.,..1.'..:.......:..�-:..—.*::::q::..
*_.-.:...11:.::��.::-....:I:::::.:.�...:.:....,1..��..-:..-�.I...I:--...:':.:.:...::.:-...,.-.::.:.;1.-..-.:.1-:...--��.q:*:..._11-:-:.:::::::..::....l.:::.",.-....1,..:...:..:.I:�d:.:-::.:..-,.-::-::I:P::.d....::,m.'-.-....".�...,..:.:.:..:'::..:..'::.::::...-...:..::.:�.
.:::.:..........::,I..-.'..,.1....-.:.,.::.::.-..:.,:::.
,.�.:
I......:...-:1.-.I-:...':,.:.:..:1.':::-:�.,::.:-��'I�...1.---.:.�:--.:�..,...:..-:..:�.'..:I1.
--.--.1....:.:-:I.1:-:-::.:�.�.I":-:.-.:l�:-I..:�."-::q:-...-�:1-::.-.-�-�...--.1::-.,...-:.II..�-.....I::.:-.
1::..-.--....:...�:.:...I=I::.:..:1iI-:-..:::.�:.-.:-.._-.:...:.1...�,..,.!......:.::.-I,-::.:::1.1I�._.:�.:...-.....�...:.:......I..:::.:...I::-::.::I-....�...�.-..-.,.":.'...:11I::--....::.-.:1��...::.q::,:1-i:."1-'..:...W:..:::.
-�...I..:,:..�,-.-�1-1.,�I-.:.:%::.....,-��.:..::.-�—�:-.-:..1..:.:---:::.:...�
-�..1.I.:-1.....-.�1.....:,.�.1�::.:.:.�-�-.I::1.i m..-1I.,.�.-..-1-.-...,......-.�,.-'::.:.I-.-.I—,.,I-..-�::...::.�1.....1.
I,':::::...�..,—.-.-.'..��:.:�.I:1--..-.....,.-'-:.::.:�...:...:':...::.._.,-.I.--...:-..:..:::::,1.I.�:..:,.'-:.I
...Ii—.-:.-'..I-.�:::,..-.:...:.:::..:::::1.—I:...:�.:-.:..::.
....�.:p.�:..-.1'-,..—,�',11....:.1.,:�:::::-11,-.:.::1.:....'.::...::.'d,.1::.�:.,:....,�..::.::::.....:11
.1-.::..:,l-.,.:---:..11.-.:.l�F::.-.1:...-:-,:-::.:11::.::,-1::-.:......Il.�..-:_-::::1:::...�.,
6-imation is_ -..-::,-.::-...:::::::.:::-:-:::.
.
.-:.,.::::1.,..�1.:..�.:,;":�...11.-:,-11::-.:-::::1::..1.::,1..:"�:.--.:::::::.:--1-.—.��-:T-...:.::..:,--,:::'.�.,...:�.-:�..::-.I:-�1.,.,..-..11-J.:—:�7..:,::I:'.q�..,�...:..::..:::1I-i:.:,..I-:,1-..".--:,:-:.:::-:..::.:.::::.-:��-�.��.:-...-�—:.1.-.....:...:I:.p::.:::...-.:.::.I::1-_.,-..::.:1.;�.....:,:-.--..:..:::p.:-:�I N.:.....:.--::.:::...
-I':.:.:.:.:----...-::::...:::.::1.:-:.:�.1-..:..-.::.:,:I..
-.;�.....:��,.::::.-l...:.-.:::-:-I..::I.:.:.:.��—...,I-..:.:.'...::.m:�..:-:.::1:.:-:::'I::..:..-.1--:..-.I.-.-:.:.-.I-�:m:-::..::-
1:i:.::...::,.:-l.-.1..1-lI.,:.:.-..I-1.-::I::::::......:.q..:q.::.:..�-l::.1.--
I,i�.-*...:....�.I:..:-..-..-::.:..::.1:.,.:::....::::1::--..
,,..:—:..:*.1::.—:.:"::.,.....i:�.::I.I.-..:.:.:�:....:::..:..:1
..-.:"..q.....�.--.::-I.I,::.:....1:::.::-:.:--.:..:.:.::..:::.�.::..:,.'�....:��:7.:I-.�....:::...-11::::q1.:.:,.1.-1:-:.::.:-:..�-::::.:.:i...,-..:...:..q-:...:.-..:.:....::F:.-*:.::.::F:I;..q..:..:.::..:..1iI:,
.*:--"...-..'�;i..:m:...1:.:,�.,.:.:.::.-:_.:..-.I,,:.'::::...:..i.*,
:.:��.*.:�:-.:.....l...:..,..:d:..:.F-:�:I1.::::.�:.:.:::::.:.:....
.�::..*.::...:—:.,.-:.:...:'...::.::.:-.::-,M:.:::::�::.:Ip::.i.:-.....:.....;,:.:.:..:.-.::.*...i.
.1:d:..:...-.:..:.:::�:..:.::..:,4�,..I.�.::.:ii--::::-.:::::.::���1::.q.::::�:::::..::..:--,-:.:..--:.:::':.":..:1::..�-':.::::::::.b.-.,:.:.::::::-:-:.::,,�.:;.,......::�.:�":.:�:::.::4::.:::::::�.
::::.�::::...:.:-.-j.�::..1-..::::.-:.:..::.=::::::,...:.p:4::.�.�.:.:.:.:::...1:I
:::::::..-.-:,:::::F.:.::::I.:1:.i--.:::::.:.::1.F.::...:.--.f.T-..�.:..:::::*::.::.:*.1::.�::...-,-:::::..:.:1..::....::..I:�:-.:1::...::::::�.i.:::::..p:::.:m:.I-1:..�:*:..:..:::i...::....--...�-:-.....::;::.:...-`:::.:--::,:::..-:.i:*.:....I....::...:.:-:.-.-,,.,�'.:..:-..::::..:-:.�-_--.:::.I.:.:.:::...:.:::::......:-:..I:.....:-,.�.�.,..:.:-I..:::.:::.:'.::,.,.:..::..::-.�::1..:.:..:.:.:�..:..::..:.-d.:
::,::.,::::..f::.�:.-.:.:::..::...:::'.:.*:-:.,.I.:...::..p.d::::..:.....,.-
n
.*1.,....:::...:..::::1..:,:.::!:...:.:,:.::�:::-...:.:.:.1....',.—.;..:.-*::..-
�.......1�,::....:.:::..:::::.,d:::..:w.:,.pq.:-.::-.::::1:-:..I�:..:....�
�:P:-...;.::1l-:.::::.:�:::.::.:.i:-...:.:::.:*:.:..:w..F::--.-...:�:::1-..1::-�,::�.,:":.:T.,:::-:.1.:...-:.::::.�:*-.::,.�.-::-:::......-::-.::::---.�.:.-:-.�:,:.:1.:::::--...:..:.::�'::�*F..:�..q::.—.:.:..:.�::;::.:.-:-j:.-�:1..,::.;....--:.1-:.;-:.:::::.*:!�:1.:::.'w:...:...::.:::�-.:.,..�1_..I.-:1.:..::...:
..��—:.-.--.�..:::::::,.�::-:::.-I��:::.,:.:.:-::-:..:.:.......,::..1.::-::::-:-::::.::::...-:T..::�..:::.q:�..-�..-..--..,.—.,.-....�::.:::.�:--:;1::m,':.-:!:..:�-:::-:.:.:.-::.....::.
..-1::..--�.�::.-:.I1:1.:::,:..1..:::..�1.::::....I..:::1::..��P'_1--,�I:�-�::1.:.-."I...:�:.-:-I.-:::.:.-.::..::::�.::-:..::::..��.1...�F:::.�-.,:...:��,.:I:.::::.:.�:-.-.,::-.--:...:.::.:1..:-,::-::1I,..:.,.::-:�::,::.!:::::I.::.1,-:.::::.::-:!.:::..:I::..:.
.
.:.
:...p...-::1...:.:,.:.,.::1.:.�:::::.::.-....-:,..-.�:..-.�,,.:F.:�I-.::1.,-...-::.:::.:-..I-
..,..:...,-..:::..:...�,:.�Id.:p..-:,-.,�
:.-:.::::-1�-,-.-Y.,I:..--..,:::.:::�-..:�
-.::-�:-1�:.:,1..-�..,.--:.:::::..:..-:..:�::1:,II�:�,::-,-.,1-:,:-..�.:-,-:Ii.:.I1.I�:-::.':.:-:�1
requ retl fopeyery ���1� l �� I*vl II Ma .. 0264_� 1(J%3 1201-,<:,�.--::1 1-:.::.:�
page. Citylt'rnnm:- State Zip Code Crate of fnspection.,.:*,�...-:::::.:.:::::.'�:.;J.1:;:�::::.:::.::::-:::::4:.].:::-::
-
..--1I-:I.-._.-,.�:-::.....-:.::-:�..:::I-...-i.:...�I:--..':I1-�p.::..:.:.::::..�.:..--.:II..-�
-1 I1�--�1-.:.-
..--:6-.::,I-,.:.-!-:::..:-:.�:-1'...1-"�::-:..:'..:11I.:..:1,..-.:.�:::...,..:,,..I
-1.i..�:,::1:-p:l;:....::.�
�,�:�..1�..:..f:
: Z .(� I5(o ..-�-.-...-:,1..:.:.�.::::::::.b:-::.-..,1..:: �..,.:1.-.�.:1..:,..-
1"...:.":::�:::.9.::.:.i—�:..::::::F.i:::,:::.:-�::1:..p::.:.n..::q.::.:::.:.::.:..::p:
�-�.:.,�1.:::-:,..::I�.;�:.i.�-�:.:::::::::!::-.:-1-�:..::.::.::�:.:::::.::.:::.:::�:.:..i....::.I.:.-..
:.1.::::w::..::::..1�:.:.--,�:-::::::::::::::::::��:.:::�.-:��!::.:w.:.::.:::::..:..-�':..,:-.:.:�::::-:::.;::.��:..:.Z..::.I::::::::.:::::-:�::::.:..,-::::pZ::::...:.::::.:.::...-::1:...
Inspecfaon results rest be;subrnitted:r�n`thrs form Irtpectrn forrris nia ;ho#I;e altered rlrl aril
way Please see ion pletr r Qs�Checklist at the>and of=the :I- I
ImpcKtan# When A General Informatc�n
. filling out forms .
on h'e computej;
use only the tab 1 Inspector
key fo move your
cyrsor da nat
Sean M Jones l/
LOWthe return. - -
- Name of ln- d, - -
key .
Capewrde En#erprses
rob Company Narr3e
153 Commercial.St .
Mashpee w . aka _. _; 02649
City/Town ::: Safe Zip Codo:l
_ 508-47. 8$77:. M: ___:.. - -._�_:. __ - - St 452 ._�__.
..
..
Telephone Number 1 Grcense fVumber
.:
: - .::
r-s. -.^�
B Certlticatlr�n
.
. - - ..
_ .
- I certi that f have erso.. ins ected the sews a disposals stem at this addres and thai e
fY P Y P 9 Y.
. Informattph reported below is true, accurate snd grnpletb as of the tune of th,e-h ort T.'.4 spez f 1:.�....-;::::m:..::::.�..:::::::`)..:=..:.::::�i-.::::..::*::*:�::::::::::::::
was perforated based on try training and expenertce m the proper functxon.andrnatltenar�oe-okon s
."1::::F.::::.
sewage disposal sys#ems 1 am a D��approved syst+�m:rnspec#or pursrtantto S trust 1;5 40
Title 5( 10 CI ! 'S 0041' The system: :
.
❑ Passes 0 ;Conditionally,.Passes: ❑\.Falls
❑ Needs Further Eyaluatign,by_the Local ApprOuing,Authaty .
. .. ..
..__
. _:___�-
..
.
1I013112a13.
Inspector s Signature ; -:: Date,
The system Inspector shall submit a copy of this Inspectrart Kepbrt to the Appro�ing Autfloraty(Board
of Flealth or—-.- w€thin 30 days 0f FoM letrng this IrYSgeetrort tf the system Isa.,shared.sys etxi pr
has-a design flaw of 10,000 gpd;or greyter,the;lnspector and the system owner shall suhffi the
.
report t0 the;appropriate reglenal office of the;DEP The original should be sent tO the sy".stem 'n`,Or
I:-
"-.:�--:�.:1:.
�
and copies-sent to;the buyer, if applicable, and the approving authpnty.
-.- This teport only descrrties car#drt' a#the trrrre of tnspeCtrt�n antl t ndelr#ite carrdttr�rta.o#ase -'`
At that lairs:This:inspection.does riot address how the system>�rr11 pe1w m t the future under
-:-::::::.:--"��::::.!:::::�:.......:...:-:-I...::-:�:::
::::.I:-:-.
w
the same o drffe sot condJ tons;of used
1
I
_. . : .
t5ins 3/13 Titia 5 Offi6ial J PeaiwF ." `+�sifria a Sewage.'Disposal System Page 9 of t j
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
y 353 Green Dunes Drive
Property Address
HARRON, KEVIN P & BROWN, KIMBERLEE A
Owner Owners Name
information is required for every West Hyannisport Ma 02647 10/31/2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I_
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
353 Green Dunes Drive
Property Address
HARRON, KEVIN P & BROWN, KIMBERLEE A
Owner Owner's Name
information is required for every West Hyannisport. Ma 02647 10/31/2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
® distribution box is leveled or replaced ® Y ❑ N ❑ ND (Explain below):
Distribution box was found to be rotted at the water line, also the box is H-10 and located in a paved
driveway. Distribution box needs to be H-20 loading if located in an area subject to vehicular traffic
❑ 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
16.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
353 Green Dunes Drive
Property Address
HARRON, KEVIN P & BROWN, KIMBERLEE A
Owner Owner's Name
information is west Hyannisport Ma 02647 10/31/2013
required for every
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than 1/2 day flow
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 117
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
353 Green Dunes Drive
Property Address
HARRON, KEVIN P & BROWN, KIMBERLEE A
Owner Owner's Name
information is required for every West Hyannisport Ma 02647 10/31/2013
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high groundwater 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-
10,000g pd.
❑ ® 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 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 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 si nificant threat,
or answered "yes" in Section D above the large system has failed. The owner or opera or of any large
system considered a significant threat under Section E or failed under Section D shall i jpgrade the
system in accordance with 310 CMR 15.304. The,system owner should contact the ap ropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Dispose System•Page 5 of 17
Commonwealth of Massachusetts
v. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
353 Green Dunes Drive
Property Address
HARRON, KEVIN P & BROWN, KIMBERLEE A
Owner Owner's Name
information fo is every West H annis
required Y port Ma 02647 10/31/2013
page. City/town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened; and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal 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): 4 Number of bedrooms (actual): 4
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 gpd
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
A Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
353 Green Dunes Drive
Property Address
HARRON, KEVIN P & BROWN, KIMBERLEE A
Owner Owner's Name
information is required for every West Hyannisport Ma 02647 10/31/2013
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes Z . No
Water meter readings, if available (last 2 years usage (gpd)):
Detail
2012—290,000G &2011 —215,000G
Sump pump? ❑ Yes ® No
Last date of occupancy: current
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
353 Green Dunes Drive
Property Address
HARRON, KEVIN P & BROWN, KIMBERLEE A
Owner Owner's Name
information is required for every West Hyannisport Ma 02647 10/31/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner).and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
y 353 Green Dunes Drive
Property Address
HARRON, KEVIN.P & BROWN, KIMBERLEE A
Owner Owner's Name
information is y required for every West H annisport Ma 02647 10/31/2013
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information.:
original system_10/22/1974 per town records
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 2
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.):
Joint were ok, no leaks, vented through the roof
Septic Tank(locate on site plan):
Depth below grade: 1.5
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 gallons
Sludge depth:
6"
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°y 353 Green Dunes Drive
Property Address
HARRON, KEVIN P & BROWN, KIMBERLEE A
Owner Owner's Name
information is West Hyannis port Ma 02647 10/31/2013
required for every p
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
3"
Scum thickness
3"
6"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
10"
How were dimensions determined? opened covers, took
measurements
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 should be cleaned soon and again every 2 years for proper maintenance. Tank is H-10, a
section of the tank is located under the paved driveway, this section of the driveway needs to be
blocked to prevent vehicles from driving/parking on the tank. Inlet cover is on a riser. Outlet cover was
not accessible.
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top scum of to to of outlet tee or baffle
P
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
353 Green Dunes Drive
lug -
Property Address
HARRON, KEVIN P & BROWN, KIMBERLEE A
Owner Owner's Name
information is required for every West Hyannisport Ma 02647 10/31/2013,
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
353 Green Dunes Drive
Property Address
HARRON, KEVIN P & BROWN;.KIMBERLEE A
Owner Owner's Name
information is required for every West Hyannisport Ma 02647 10/31/2013
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
oil
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 was found to be rotted at the water line, also the box is H-10 and located in a paved .
driveway. Distribution box needs to be H-20 loading if located in an area subject to vehicular traffic.
See attached letter.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
USubsurface Sewage Disposal System Form-Not for Voluntary Assessments
353 Green Dunes Drive
1W -
Property Address
HARRON, KEVIN P & BROWN, KIMBERLEE.A
Owner Owner's Name
information is required for every West Hyannisport Ma 02647 10/3.1/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
2x1000 gals.
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Both leach pits are located under the paved driveway with no access covers to grade.The pits were
video inspected from the distribution box. Pit#3 ( on as-built)was found to have approx 4.5' of
standing water with no signs of past hydraulic overloading. Pit#4 (on as-built) had 6"of standing
water with a stain line only slightly higher. With no access to the pits it was not determined if they are
H-10 or H-20. Town of Barnstable regulations require that all septic components that may be subject
to vechicular traffic be H-20. See attached letter.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
353 Green Dunes Drive
Property Address
HARRON, KEVIN P & BROWN, KIMBERLEE A
Owner Owners Name
information is required for every West Hyannisport Ma 02647 10/31/2013
page. City/Town State Zip Code . Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,_
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
.: '..
R-.. of Mas, ... efts
r. fist a 5 f iF I :".. :p:-.:::-.-::w..::..--:--.::..,::.,I-..:.::.:,':,:.0..q.....-..:.::...-..:I:,I..-:...:.�...:.:...-.:.:.:-...�':-:..::.-...�:...-p.I...:.,�
:....:,
::.
T
Subsurface Sewage DispasaC System Form trot fiar VOW zlar Assessrsients
5 Green I��rries C?ri�e
pew
Fro A..dress
..
HARRON, KEVIN.P&;BaWN, KIMBERhEEA :
Owner Owners Marne
[nforritatron fs Ultest H aMiS ort .. ___ Ma 02.4,7 1S1I.39120.
..
tequtied for every _,�___Y.. r
page
attytl owrr : -:: State, Ztp 0.:ode Oa#e�f 1p�pecton
..
..
D S 000 nfornWi6h. (cons.)
Y :
Sketch Of Sewage;D!sp4sal System Prd�tde a:Vrewfi tt�e sewage disp0silys�em, �rfel�d[�rr� s to
at least iwa permanent.reference landmarks or bench�trks; t,ate a(l welts wathi 1 pQ:fi;et I,neat ... ..:.
where public watersupply enCethe buIdEng eheak arty of`;the boxes beJev�.
® hand s#etch an the area belvi<
dl awing,a, hed soporately
. � u
.. 11
. :'
... .. ....
-:. ...
„ ..
.
t.
. .:
j 7'. :: :
3 14, r xs
R Z '
4
.. N2 ::
..... .... .... :.:: .... .. .. :: R ..
:.I:=..I.�-.I�::-.-�-.-I...l::.:-q::p::....:-:.:::.:!...::,::::.:-,.::.::-::.:.,.:::�:.:I,p.:*:.:....-:,:-:::p:.:..:::::::.......-:::.:::::-..:.I.:..::m.�.:::...::::.,:-:.:...I::-:.,:....�:::.:-:-..::.:.m.-1::,,.:.--...,.1...:.:1.::l....;...:I,.:...:*;::.I.I.�..w..:::::,.-.,.:,..'.H::,,p.:l..:;...::..:.::.::::.:i I:-:...::'.:.::�:::.:..:::.::::.:::...-;,.::::I:-...F.:.:.,:.::..-.::.:.:...:::I..:::.:.:-.::.:1I.:.:.F..:::.,.-:p:.-...:-.:.:I..-.:.-..,�-:..::.I..::.-l'..-r.�.:'-.:..1.p.-.:...�I.1.-:.l;.:I.:.I.:.p::I�.:....I.II:-.-.—.-:..--��....-..-:.-�...:.-.:..:'.1:--.-.:I...::1.1�-.....:..:�:-:.:..-:.-:..:.:�...-:,I..p::I-p:..
A , ..,-:..�.,.....�-�:.-"-:I
,-:..-1-..;:.-.-r.-,;.11.::....-..11:...:...1.:.-,:..-.-:..1:I.:..---..1,:I-�:-..11:;.:.:...1:I::..:.-.--::::.�:..,:-:-.:..-:::.::....I.:.-�:..-I.-I�:.!:....:I.�:.:::...::::.-:..:::.�:,--.-1'II::�-7..1':I:-:�:I-*...::".1.*i::,.:.:.1.:::.:...:::.::.::,..4-.::.:::..�:::.::��.�:.:.:,::::-�::-�,.::.�::1�:::4....-....:.:..::,:�.:I-:p:.-:�:�..:.:..:::,.-.-I-:.....:.:.:,-::..:i:.�:.-i.,-:.:.,...:-.-..:.:-.:I:o..-�.:.'-...:.-��:::.:.:.'.1I:-I..:1::.-I,:-:-::::.-1I':.:-:..:I'-:.-::.:.�.-,--,�::I....::...::,:...::,-I.-p-.....:..::.--.p.I.:.:.:I:..:::�:I:..:�:I.:.-1.:.::Il..:::.-,::.-.:.-..:::::..:1..:::-,...::.:.:*.p:.-::p.::.::.::.:4-.::.::::-,:..:::p.-.:,...p::::.-1...::p:�:-.-..:q::...:::.:....I.:p:::.,-::...:,:::�:II,...:::--:...'.:-�;:.�..'.:...::.::..11.:...:!:pI-11....::-:::....:::::�II....:,::..�...:...I�--.:.-1..:.I�,.--I..',:,.I...':I......::.I,..----.�'.:...:.-I..:1.:.:.l..:-I1.:--11::-:
.-:.1..I::.:.
�.A:I..1-..I i...:,..�.::..�..::�.::*,....-:14:...:::1....::.�.,:.,...::..:...-::.....::.q::l.;...�..:.::::..-..::.-.:::.p..*...:::...:.�.:.,::....�p.:::.-...;:".:.::"::::.C..-.,::.�.-:.�:.�1:.�....p:.:."1.,::.::
(n( ry .. .�.:::..-.,...-.,:.:.F-
.:I:_;.....:
::I.1.:--I:1 1-:I.�:-1,--.:I.l..-.I.:.....-.-.--.:I..:.-::.:...I.:..�:I:,..I..:,:.::.:.I..:.,..:-:I.:..:....::.1::...:.:...-1.-:*.-..-I::I.:::..:..-..:..:..:m.:.':I.:.:.-:...!:.::.
'-.-..:..::.:....,1...,-I..::.p.-.I.-.:..::.::...:.:.-:p.:...:-....::.!,..:d:.::..:..::1....:.:.::...:.,p1.......:...:..1.:.:...::....::I..p...::...p�::...:.I:..::..I:.::...*.....::.:,:�.
:',..:.......:1'...:....:..:.:,...:....-....�1.::.........:.-.�:.--.......:.1.:�.:..........-..1.:I:............'.:I::....-...I..-�1-':.:-I.,.-N
..:�..��:::I:..:.:.�::.�I...:::..:I:.:.
.. ,.::..I:::,.,.F.:I.,1�:-..-...I,;:....:,:�_
,�.�:�.1..:.::�-I,,:�:.�..-.::.,,F:�.:.:::.:�:�
.. :lip a0 ��.:.::.:::�,:..-��:.:.:.,.::..-...:":.,::.:�..�.....I.:::.::..d.�:.
.. .
... - ..-.::..d.�:...'
.�,��::.::..,...�:.::..�...;�:::.::.:.�...:.-::1.�.."::.:.�.�.�r:::.::.�..-14:::.::.�..
..W
:I:::.::.I:�?.I:.1:
�-.:':.�=:..-'-.:�-�.:�e�:.....':.---:-�.-.-:I-.
,:�I:-.1I..�
I-:..'.=�.�.,':.:-:1..-.-..-.'::.:::.:-1,..'.:.:.-..,:.-�1
-:.-::.:.::...:1:�I�::1:1:-:.:�:...:.:,*:.:�-:..q.-:-�.,q.-.:.:.1--.:-
.;:--.:.:.:1-:.:I:.
..::::.-.::..::.....F.
..:::.�::..:.....F,
.::w..:..:....I.F:,.:
:-�.::.q:.:::...q.:..
..
:::::.:::.....::;:::.:..q-d...:.:.1:!.:-..:I:.:i,:::-.
..
i �>/� ` 1.-.-.:.:...1:::.1:.:.:.:....:::......-..:.;.-....b:.�:.q:-.:.:-..:.....l:�:�,:..q..::..:.d....
S%' :' '�:�-:I.I:'.
,:-.:.-.:..p�%':::..1:1.-..:!1-�':,.:1.--..::-..
:,.:.:-.:....:.::l::.:-!.:...:..:..1,=:.:.:-4:q.:-.:...:.-
.--:....::..:.-.
::.�.:.-:.....::I�:.::.:�:....Il:.I-..:.
::-�.--:I:.:b.:...�;..,I:.::p:-
,::�l.:q-.-
..�
:.:p.:....�F�:
I I .. .1 11 � .11. .I...-.1...� -...-.............. .. ,
111. I.. . ..' 'I'll , 11 .1....- ..- :. i ., I I I I I . -.11-1- ... .... . . d................I.. .....::....::l-::: - I.. '��''.... .:.::::.:.:::::: :::�:�:�
. ... .. .. :::.::�:: �.- :- -.-.......�.....b............ ......-
. 1 � . .11, . .1 -- - � ..I 1. I . I I I .....I ......: ....�....I..... ... . 1 -1, ,
I .I .. . I 1. . I I. I 1 . . , . ----�-- -- ::: .,:::::�:::::.::�:,::.*..'' ."....�...
�1. . �. I I I --�- 11- .-1. I. -11, ..... .. -.1.1--.:.-:-::::: p:::-:: �
I .1 � 1- � 1:1 I I I-:: : . . .... .......I.I 1. ..�� ---..... .- - -11:- ; * : -
,�... 1.I-- I . :.;:::: : : -...........�.... ....�.....
- I . I I....- � I .................. --... ...11.1. .1 :.:: ::-...::: :.::::.- � �� .......I...---........I. . ::::::::::::: ::::::::
I I I I �, - . -::-:-::::�::: :::; � . I-I... . - -- :..F:.:l:::,:- -! :::, bl-: - *: .....I.............
-.................. ........
I... 1 . I� � I I..- . I .. - I I -..I....I .- .
. I I - - . - . .... : ,. . ..... I q::.-::p--:.-::.:.:... .:- ::::::,.- -:-....... .......�--........ ... �.......:::::::::::::: ::::::::
- :.. : - I.''. .. - I:- . , .. . .......�.....::.............. .......�
I 11 . :1 � *. - :::::::::: : :::::::::::::::-.-::::::� .: . :::::.::.::::::.:�:::::::::::: : :::::::::;:::;::: : - : � . -:::::.w::l:: ::::::::
:- ::. � - - I . - - I I.... .::::: . : .......-.''...-
-.1--.1-1 1-1-1
- 1 . � :::, 1.1. - - . - ::::.:::: ::,:::::::::::::::.:::::�::.: :::::::.::::.::::.:::::::.::,�::.::�.::�:::--q::::::::�::�-;::- *
.. � - I..... . :: ll::::::::.w:::::: :::::::
.. - . 1: .::,: ��.� - 1-1. -.1--l'....:-:� . . . . �,.:.:.:::::::..:..::..::.: ..::: ::.::::�:,: :::::::;:::::, ,* 1-1- : *::.:::::. : -..--:::::-:::: ::::::::
: :. �. ,:- ,.�. , - 1 . :, - . ., --::�: ,�..... - :.:.--::::.. :: .: * � ::.. --.-.-::::.:.:p:::- i ,.,�::,::::::::::::::::::::.:::::::::: ::::w:::::.-:::::::..:.l............. �.......
�.. �I I..I ..I- -. . - I -�::-,-:�:::: : : :: �- .... :: :-::.:�- - : :.. ::....: �.....11 ----...... :::::-::::::::::::::::::::: * * - -
I ..1 . . - , - ., , � :: , - , ,.:.:::::: : ....-.-I......I.... ..- 1.I......I...--...::*::::::...:: .:-..�.�. ::::::::::::::::::::::::.:::::::�l:: . .......
� --:. .�-: -l.:--...-....�......I I..�I -::.-::::... :: :: .:::::.:�- .I I I...11.1 -.1........:::::::::::::::::::::::::::::.::::�:::::::::::::::::,.:::::::::-*::::: : :::*� :::.::::�.::...::,:::::::::::..:*:***,:q
. . . ....- . .. �. . . ,:::::.:::::::.:::::::::::::::::**** - .11. .:.:4.:-::-:::::: :1:............ -...�.
, ::::::::::::::::::::::::::::::: :: :. ........� ...--
, � '', .
.11,- ,.
I I .. 1. .. . .:..::: : I I I I...---:-:--::::. --l-.... .�:.-::-::,.l.d.:4:;:::,:: , . .. -...:q-.;-::::::::: 1- - .--:!;. * *
I I .... I ...::::.:...� . .. - -..
... I. . �.. .1.1 1. ...I . ., ..1. 1-: -.-- --: � 1. . ..::::::::,::::::�-::::::: :: i:: q:::::::::i:::: : : ...,... :::......�....�............. . 11--l-Ill.
I.. �.: ::: ::.:::: : .-,: ::, ; :�. ,- . .. ..- . I I 1. .. I...�-.1......11.....,:::.: : ,: , I...I...I�......11 .111,....::::p. ,::::!:4:F:bll: :::q::::
: : : ... - I � 11.1 , - '' .. ...'''. -....:: :::::::::.: .... ........................-.1 11 I.., I.. -- .1........1-1.11...-............... -.................::-::qqq4::::: ::::::::
-:--.- � I I...''.. ..., � - .111. : , - . .. .
- ..-.: 4.l .I I....I.I. 11,: :: : =: .:-:: . .111, I....I'll -p:q::q::: . I:- . : ,��*. :� �........�,:::�:.::,,:,:,:::�.::::::::,:.:'':::,: 11-:,:: p!!:: ::::: :: :*p
. I .........�.. , . .''..I ..
1. .1 . I .... - . 11 ...I.I.I.-I -- . -- :I - . -1. . 1. .- ...--::-:::i�-::::::;::.:.:,.' ':::::.::.::.::,, ::.. ...F.- . ,: �,i :
I I . 1 . I ''''. . .1 -1111-11-1- 1.11'' . I......11.....-.1....-..: -.1-1-1-11, - �...... �
- - . I.. - .. . i:- .,::::: :: -, - ---, ;4::iii::: ::::�:-.::::q::,F-
. I. . . .. 1. 11 I .. -� I'll,...:::�::i :::: - :...:-:: :::::-:::: , :::� ::::..::,:::::::::m ..... ........................... ,- - - : i. ,.
- 11 1: I � I 11 , ,p.:-, �... .. .. . .........:..:::, ....---- l:, -::::.... ...............................�............�............... ::.,::::
- �.I I - I � . . F...: :, - .. . .... ....... ., - : :::::: :
- 1. - ::::::::: ::.... :::. ... � . I ,, : . : . , � I.,,.:::...I: ::::i.q
:::
.I I. I. - I: :F:.- --::.::q,:...� .::,:,: ql-I�::::::::::: :� ..:1: ::� : : . .q : �,
11 I I:.: - � I .. 1. :::::: ::.p . ,� - , 11 -- :::::
- - ::: � : ..... , , ,, ,,,::,: ,: :. i .: . , -:,-:-:::�: :::: ::::.lb:.:.. .... ::-::-:p-:::::: - r : ,: :::::!::::::::.:::::i: ]:; - .
.1 I . ......... . .... .. :::�---:: ;;:;��:::p.:: .. �l...... ,::::: �::: : ::i:....:...�-:::-.- -b I I . �::::::: :::: .1
I- :, - .1 . - :-... ...... ......... � ...-.......-Ill. .-. -::-::--: ..� : ��:::-::::,:,.:.:::: ::::p::::::::::::�i q:: :::,:::::::::::::,::::::::::::::. p::mp: ::::::::
. -i: , ,. I...., 111 .11.111.1111: ::::::::::::::i.:: ::� - -... ..............i;��::�: �........... . -::::::::::::�:���::::::: -......:F,::::::::::: ::::..:
I: - ..q:::::::-.:::: ::: ::.. :-::::::: ::::::::.:::::::::�:::;::::�:;..::.::::::::::.:::::�::��:,:. . , . � :-.....
. : � - . . 1:1 I ::r:'::1:1 :111:-l�-....... ��i.......- --...- ........1.1-11...I.
I 1.I�.I ..-1. -.. �::: ::::,:.:.::.� ..::::::,:::..::�:� ''.. . . p::::::.p!m::: :q -- . ,..:,::::�:::::: ::.:i--:....�,�......: - : . , .. d...-.1 ':�
� I . .�-::::-:..:.... .::: .::: , .-.:.::::::::: ::::::::::: : ::::::-:::::p:: :::::-:::::::::,:.:.;-: : :q:,w,::FFFFb,:::i, :=: --.''':....:::::::: :,:::::::::::::::::::::::::::
- - - :.:.. ......: �.::1:,::: I- � -1.1.111''. --,......:::
.::::,. �: , :.- ., I . . .. --: - -- ::..::,, ,. . . :.. ::-:,::p::::p::::::::: : , ::: :i-:�,: ....;..............-.......::-::::!�::::�::::q:::p::�:- . .- ::,::::::::::::,::
.1...:: ., , 1 . 11. .......I. ...l. I I.; I-.......I� ... . . .. . .. 1. � .. � � I 1. ..I.,I-..,�.I 1.I I I.....�.-,,.�..........I -.....,........�...........I.I.,�.....-.-.-.......�...-.,.,.,.,...,...*............ .....-
, -
-.1-1
----11 . .., --- - *:� -........�, ,
........ ....-.........- .- ..
:: :: . �''. -111.1...-...........''.-..--::-::- :.- .;:-:F:lF::lFFq.::::::, - .: :::: . �..........-.....�...........��::::::::::::::::::::::::::::::�::.::::.::�:..
-:-::::::. : :: .:,.
I I.. I I� , ::. : :.I I .. . 1. -1. ::::::..:,:.,..:::.::: ::::::,::::::::::::::.:,::::.::::::.:::K I.". :1:::,::...
. I 1. . .. I I I -... .:: ::::::::: : : . . b--=:i.::.-::.:-:l. .
I I I . .. I . . .1. .. - I'��' ..,.,....'�:..:::,::. .:::..:,:,::�:m -::::::;:p:�:::::.::.. I -1. � w
1. .. ::::::d.::::::::F::::w::::::: 1 . . - :.......... .........
...I I . I .: I . 1: --.. . ::�::.,:: ::::::-: : : :: :: *: : : :, - : :.:::::::::::::::::::::::.::::::::
� . . � . I . . :....., . 11 �::�: ... �, �.....--.- - --,...................�
-I I I I. . . . I .- �*, *- .. . ......::.........-...... � � ..::.::: - ::::.... -..... -::. :.:..::::.:::::::::i::
- -, - . . I I .::: ,. � -- . - ... ... - . . : d d . - :...:. ..,-.
. .. .. --:: I -.: : � .. I � �- : : - ::,. - m .:.... .�.........-.......... ...:.:::: :::��. , ** .....:-....':, :- :.:. -::w::::m:::::m::::::
� - .- - .. 1. � I........ ...:-:-::4:F: ,: ., -...---:: ..* :
- ... .. - I � ..:::.:. .. 1: , . .
:��I::.::.....:.-��:.,::.�:..1:.-:.::I..:�:I..:.�:.:::-.�:-:I1::--::.-::I:I.:.::,::-::�,.l:-.I::-.:.::'I.-:-:-,:::.:I.:1::.-�l-':'::,:.1..:.:,1I.�
I.-..-:.. . .. I II .I.:-1..:..-.... - ..1 .1..
t-. 1 3tt3 Tdle S Mii l�&pect�art Fan±:SubstiK- S 4O�Vg osat$ystem F-a0e.,I5& f 17::::�:::.
Commonwealth of Massachusetts
a Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
353 Green Dunes Drive
Property Address
HARRON, KEVIN P & BROWN, KIMBERLEE A
Owner Owner's Name
information is required for every West Hyannisport Ma 02647 10/31/2013
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
`❑ Shallow wells
Estimated depth to high ground water: 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: 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:
Groundwater elevation was determined by accessing Town of Barnstable groundwater contour map.
Property is elevated compared to nearby surface water, Halls Creek
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
353 Green Dunes Drive
Property Address
HARRON, KEVIN P & BROWN, KIMBERLEE A
Owner Owner's Name
information is required for every West Hyannisport Ma 02647 10/31/2013
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Y
,
COMMONWEALTH OF RIASSACHt;SETTS
__. EXECUTWE OFFICE OF ENVIROI�A4ENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE RTNTER STREET. BOSTON NLA 02108 (617) 292.5500
TRUDYCOSE
Secre:an
ARGEO PAUL CELLUCCI 8 �'ID B. STP.�HS
Governor SUBSURFACE SEWAGE DISPOSAL � ommiss:c:F:•
SYSTEM INSPECTION FORM 9
Ay b PART A
(Dv1, CERTIFICATION
%S6 �q
_ t/ z I re
Property Address: ` 1 '`"' Name of Owner Z5cse_,P v-, �41 v
V&kk, VAddress of Owner: �O
t q
Date of Inspection:.(4'V1
Name of Inspector:(Please Print) •�Q cy C �7t��CC_l<v � 9g9
am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.00
Nam: �
Company Na : 147-,/_ i '1r r Eta Hr'ram,u A,,s t�'�u I -
Marring Address:-?.n, A,a 1 77.
Telephone Number: rj o —Lt 3;z
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
_ Conditionally Passes
_ Needs Further Evaluation By the Local Approving Authority
Fails a
r ;
f
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 thirty (301 days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
`shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable,and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 py 1orat
v PnNrd on Retyckd Piper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
'roperty.Address ryl .k
Owner:
Date of Inspection:
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
-� I Have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
L • t,
i criteria notr evaluated are indicated below.
COMMENTS: X
NUN
- B. YSTEM CONDITIONALLY.PASSES:
One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon
fiom'p�lli6 n of the`lreplacement or repair, as approved by the Board of Health, will pass.
Indicate yes, no, or not'd to mined(Y. N, or ND). Describe basis of determination in all instances. If "not determined%explain why not.
V
9e'septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
i; ompliance(attached) indicating that the tank was installed within twenty(20) years prior to the date of the inspection;or
the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipets)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipets) are replaced
obstruction is removed
distribution box is levelled or replaced
_ The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass
Inspection if(with approval of the Board of Health):
broken pipets) are replaced
obstruction is removed
revised 9/2/98 age 2 of.11
1'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to deter ine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE H 310 CMR 15.303(1)(b)THAT.THE SYSTEM
IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH ND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of'a bordering vegetated wetland We salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBL C WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC H TH AND SAFETY AND THE ENVIRONMENT:
_ The system has a septic tank and soil absorption syst m(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 soil absorption s tem and the SAS is within a Zone I of a public water supply well.
_ The system has a septic tank and soil absorption stem and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption ystam and the SAS is less than 100 feet but 50 feet or more from a
private water supply well,unless a well water a alysis for coliform bacteria and volatile organic compounds indicates that the
well is tree from pollution from that facility an the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine dista ce (approximation not valid).
3) OTHER
a'r
revised 9/2/98 Page 3of11
F `
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following: conditions exist as described in 310 CMR 15.303. The basis for this
I have determined that one or more of the following failure
determination is identified below. The Board of Health should be contacted to determi a what will be necessary to correct the failure.
Yes No
_ Backup of sewage into facility or system component due to an overloade• or cogged SAS or cesspool.
_ Discharge or ponding of effluent to the surface of the ground or surfac, waters due to an overloaded or clogged SAS of
cesspool.
_ Static liquid level in the distribution box above outlet invert due ton overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
q P
_ Required pumping more than 4 times in the last year NOT du to clogged or obstructed pipe(s).
Number of times pumped_.
_ Any portion of the Soil Absorption System, cesspool/fa
rivy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feetsurface water supply or tributary to a surface water supply.
_ Any portion of a cesspool or privy is within a Zone Ipublic.well.
_ Any portion of a cesspool or privy is within 50 Ile of a private water supply well.
_ Any portion of a cesspool or privy is less-than 1• feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
•colitorm bacteria, volatile organic compounds ammonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the folio . ing:
The following criteria apply to large systems in adgition to the criteria above:
The system serves a facility with a design flow if10,000 gpd or greater(Large System) and the system is a significant threat to public
health and safety and the environment becausd'one or more of the following conditions exist:
Yes No
the system is within 400 feet of surface drinking water supply
the system is within 200 feet d a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system sh 11 upgrade the system in accordance with 310 CMR 15.304(21. Please consult the local regional
office of the Department for further information.
revised 9/2/98 Page4orn
I
A
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: s x-
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
None of the system components have been pumped for at least two weeks and-the system has been-receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
As built.plans have been obtained and examined. Note if they are not available with NIA.
_ The facility or dwelling was inspected for signs of sewage back-up.
The system does not.receive non-sanitary or industrial waste flow.
_ The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System,,have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soif Absorption System on the site has been determined based on:
_ Existing information. For example, Plan at B.O.H.
_ Determined in the field(if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
(1.5.302(3)(b)1
The facility owner land occupants,if different-from owner)were provided with information on the propermaintenan".of
SubSurface Disposal Systems.
revised 9/2./98 PageSofII
f
Q
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
a SYSTEM INFORMATION
Iroperty Address: .�lu
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flowal�W g•p•d•/bedroom.
Number of bedrooms(design):- Number of bedrooms (actual):'a)
Total DESIGN flow
Number of current residents:-C-p
Garbage grinder(yes or no):_
Laundry(separate system) (yes or no):A') ; If yes, separate inspection required
Laundry system inspectedieg]or no)
Seasonal use (yes or no): t-:S
Water meter readings, if available (last two year's usage (gPd): e^� (-�'"� ?�aSr=�•,
Sump Pump(yes or no):
Last date of occupancy:
COMMERCIAL/NDUSTRIAL:
Type of establishment:
Design flow: qpd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings. if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
rB ! G�'sL t Y SFa ?�C L Lb� fit 1�a.,[
System pumped as pan of inspection: (yes or no)_ 1
If yes,volume pumped: gallons
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)
IIA Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information: 1 --
Sewage odors detected when arriving at the site:(yes or no)
revised 9/2/98
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
+ropertyAddress:
Owner:
Date of Inspection:
BUILDING SEWER: 100
(Locate on site planl
Depth below grade:_
Material of construction:_cast iron_40 PVC_other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints, venting, evidence of leakage, etc.)
SEPTIC TANK: { C
(locate on site plan)
Depth below grade:Mob.
i AT(r1 -t
Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_•� Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: -.(AyL.—)0 r
Sludge depth:
f
Distance from top o sludge to bottom of outlet tee or baffle:s.210-
Scum thickness: it
Distance from top of scum to top of outlet tee or baffle: I Z;
Distance from bottom of scum to bottom of outlet tee or baffler
How dimensions were determined: P&M
'amments:
(recommendation for pumping, conditioq ot,inlet and outlet tees or baffles, depth of liquidlevel in relation o outlet invert, structural r{ttegrity.
l ai
evi ante of leakage,etc.) r 'ti �� ��a t
/
GREASE TRAP: 1�j
(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_Fiberglass _Polyethylene_,other(explain)
Dimensions*
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping,condition of Inlet and outlet tees or baffles,depth of liquid level In relation to outlet invert,structural integrity.
evidence of leakage,etc.)
revised 9/2./98 Page 7or11
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address:�7 ` 'G"
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK:&-O (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction: _concrete_metal_Fiberglass_Polyethylene_other(ezplain)
Dimensions:
Capacity:_______gallons
Design flow: gallons/day
Alarm present
Alarm level: Alarm in working order:Yes_ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX: ,� 6
(locate on site plan)
Depth of liquid level above outlet invert: .<��� f�
Comments: -
(note if level and distribution's equal, evidence of solids carryover, evidence of Ilelkagepinto or�onu�t of box. etc.)
v.,
PUMP CHAMBER:V1-b
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber.-condition of pumps and appurtenances,etc.)
revised 9/2/98 P age 8of11
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'roperty Address: :�Sl (ow"N c NzW
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS): Q.
(locate on site plan,if possible; excavation not required, location may be approximated by non-intrusive methods}
If not located, explain:
Type:
leaching pits, number:'A ;o'�_'
leaching chambers, number:_
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, darppP soi�t�condition of yvegetation, etc.)
1- Ws )Ea..:
CESSPOOLS: c�
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
)epth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
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 or ponding, condition of vegetation, etc.)
revised 9/2/98 Pote9orIt
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
?'$roperty Address: ;7'j, q
)wnef:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
PIZ
art % 5E i .
revised 9/2/98 Page 10of11
t
SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
roperty Address:SSSI
Owner:
Date of Inspection:
NRCS Report name % - — ---
Soil Type_ — -------- -
Typical depth to groundwater_____ —_ ---
USGS Date website visited p 0
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope k�4 S V.eC\vL C-
Surface water -A
Check Cellar t)t;j
Shallow wells pi4
Estimated Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed)d U ,
4„
revised 9/2/98 Page 11 of 11
A
r r.
} LOC&.TlO 5EWAC4E PERMIT MC
WSTALLER 5 W&ME ADDRESS,
5UI DER 5 tJ AME. ADD_ RESS
Y
D ,TE PERtv11T 155UED =��_ �_ � - - -s
D ATE COMPLI &KICE ISSUED : P'_ S y
� � u
y
�r
r-
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
y,.........oF.......P. -4,6_ A ----_------------------------
Appliration -for :41-4pofial Workii Totuarurtion Vrruift
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: lee
l
._ ...... M
.................
Locati Add / or t No.
/! f10 1/ `�� -��------ gr / am'
....................®,-�_ p_._._`-'�--`-t----.__.ne=., _ .. _....•...-_......_. .... ._. .If/i''l`2 /�?�.__.=__..__.._�./_____r.[__ �/t/__.__.._._..1._..
CIv
av'(� f- ' )✓ �+ � wl v- l�i i�°l// -------•-•----------
Ad
-M.
Address ,r
d Type of Building] Size Lot......11__________-----------Sq. feet
U Dwelling—No. of Bedrooms------------1-5 .Expansion Attic ( ) Garbage Grinder ( `�
pa, Other—Type of Building __________________________ No. of persons.--------------------------- Showers ( ) — Cafeteria ( )
A'' Other fixtures --•---------------------------
W Design Flow__ _____________J'�-- .•-----._-------._gallons per person per day. Total daily flow----__-___ �—--.-.--_---..........gallons.
WSeptic Tank/- capacity]Liquid ca allons Length________________ Width_.__..____._.. Diameter---------------- Depth P q 1 -�---------g
x Disposal Trench—No- -------------------- Width.................... Total Length-------------------- Total leaching area....---------.------Sq. ft.
__-_ Diameter•-figj(P-Depth below ' let_...._
Seepage Pit No_________ _____ � ___...____ Total leachin : ea___-_._.___.___sq. ft.
Other Distribution box ( ) Dosank ( ) L _ ��
Percolation Test Results Performed by.......................................................................... Date-.---_--------_------------.--------.--
a Test Pit No. 1--___--__-___-minutes per inch Depth of "Pest Pit.................... Depth to ground water.........__-_-_.__.__---
44 Test Pit No. 2----------------minutes per inch Depth of Test'Pit-------------------- Depth to ground water--.--.-.--_----._____-.
e -- --- - t -------•--�- - e-- -- --..
--------- -- -
Description of Spil----antl ........ �!z - ---I-
x
----------------------------------_---------------------------------------------------- _-_ 'ti___ __ p_. _.__.______..__.................... ------------------
_
U Nature 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 Article NI of the State Sanitary Code a xldersigned tl agrees not to place the system in
operation until a Certificate of Compliance has be iss t e o o ea
ned - -- ---------•---------------•• ------------
D e
Application Approved By-- '------ -/ ------- ---- --------...... V
Date
Application Disapproved for the following reasons:._-•....................•-._.___. -._.---.--------._------..----_-----------I.______-___.--------•-.--.. ..
------------------••--------•---------------------------------•--• -----------•------••--- ---••----------•-----.---•---•-------------•------------•-----------•----------•--• -----------------------
Date
PermitNo......................................................... Issued.:......................................................
Date
Id 0:0;
............ Fimic..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
'>N..........OF.....B.a!Y: ..............................
Application -for 11!ipoiia1 Works Totu3lrurtion Prrutit
Application is hereby made for a'Permit to Construct or Repair an Individual Sewage.Disposal
System at:
yef-J�
...................g------- ... ........ . .. ...............
0
-------------------
_0 d
.................................... ........................ ........................................ . ..... ... ..................... .... AM>J,. ......................
---------------- ..................................... ... . .......................................................................... ...I................
Installer Address
—314,#1&0 4.
-1� Type of Building Size Lot-----......................Sq. feet
U - I
Dwelling—No. of Bedrooms------------2-----------------------Expansion Attic Garbage Grinder
< Other—Type of Building ---------------------------- No. of persons............................ Showers Cafeteria
aOther fixtures ------------------------------------------------------------------------------------------------------S.............
.< o-�-----------------------------------
;� W Flow................1�6_C. ......... aily'flow......... 0-0
W ank J ................. --gallons per person per day. Total d, ............................... ----gallons.
P� Septic T, -Liquid capacity/#.4"-- allons Length________________ Width..___-.__....._. Diameter....__.....-_- Depth.-..---_--.-....
W
x. — area Disposal Trench No ...... --- Width.. Total'Length.................... Total leaching- -----------------sq. tt.
Dianieter.1 epth below _n�et,�a_ Total leachingarea Seepage,Pit No.......... ......... _AA ot --------------sq. it.
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-..-_-_-_--_----..-_:_..
G% - Test Pit No. 2................minutesper inch Depth of Test Pit-------------------- Depth to ground w Xer------------------ -----
------------------- -4-----
L...... .. ......J,
ex-t
0 Description of Spil---- 7"
..........IT........ ----- ................................. ------------------ ....../---
-------------------I------
U - -------------------------- ----------- ............... .... ..........:.... . ................
-- ------------- ---------------------------------i��
-------------------------------------------------------------------------- .....................................I-------
------------? -------------------------
-- -- ---- -------- -
U Nature of Repairs or Alterations Answer applica e--------------------------------- --------------------------------------------------
-------------
-------------------------------------------------- ------------------------------------------------------------------------------------------------------------------------------ -------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Cod rsigned agrees not toplace the system in
operation until a Certificate of Compliance has hee iss b of. I
......... .........
ApplicationApproved By.............................................................................I-- --------------- ........................ -------
Date
Application Disapproved for the following reasons:.................................................................................................................
....................................................................................................................................................................................:.....................
Date
PermitNo......................................................... Issued---- ------- ........7Y........
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QV HEALTH
..........................................OF...............................................I.....................................
Trdifiratr of "JIT'Jamphaurr 4--l-
the Individual wage Disposal System constructed or Repaired
by.�te............)........................I................... ...............*................
st
at............... ..................... ........................................... ----------------------------------------------------------- .................................................
has been installed in accordance with the provisions of Art-
tle4XI/f The State Sanitary, Co
Individual I.. ... .........
................... .... ....... ........
application for Disposal Works Construction Permit No. ---------------------- 7/...... in the
--- ... .....
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUA ANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. 17
DATE -----_-_--------_----- Inspector---- .......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR F HEAL
..........................................OF... ....................................................................
No......................... ............ FE/ ..................
PermissioVis he .... .......................I......
g.�;by granted------ ----- ---------------_-.............. ------- ------- - -------------------_-------
to CoiJtr5-CQ( e s I
atNo.................. ........................................................................... -------- -------------------- ----- ------- ---- -/;�/------------
troet
as shown on the a io N Ued----------------- ....................application for Disposal Works Construct rllol;� ) &,44
................................................................... ...................
Board of Health
--------------------------------------
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
I
8R.001f
3 f
e
t
f
R
l
130.00
oo:OID'
+._I3,C. E 'N D V P�'E $ ID R I e,
f
WA
. S
f �
j ♦ t LLUI
MR. GORDON M. KELLEY
P. 0. Box ONE
W. Hyannis Port, MA 02672
LOC&.TI 5EWAC,E PERMIT 1.10.
�� 0� - - -
VILLAGE '.
IMSTQLLER5 1J&ME P, ADDRES t.
t3Ut
DERpp 5 ►.! &VAF- ADDRESS
o r
DL�TE PERMIT ISSUED
DATE COMPLIWACE ISSUED :
I
13®�c
r