HomeMy WebLinkAbout0039 RED LILY POND ROAD - Health 39 Red Lily Pond Rd.
Centerville
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No 2C�R
`La CAT 10 SEWAGE PERMIT NO.
1.4 u 14"�- La
VILLAGE
I N S T A LLER'S NAME i ADDRESS
bar. Ca. dic-
8 U I L D E R OR OWNER
C
DATE PERMIT ISSUED
`0 - �- $�
DATE COMPLIANCE ISSUED
Am
THE COMMONWEALTH OF MASSACHUSETTS
44
BOAR® OF HEALTH
39 --.........1.0-W-N.............0F..... J�2-►1. ..�.a b j'=
lr�
Applira#flan f'ax Diapnsal Works Tnn.'itrnrtiun Frrutit •
Application is hereby made for a Permit to Construct ( ) or Repair anIndividual Sewage Disposal
System at: t4 ?
-•--...�- f '!.`.):... .1.5. .i?_. ±.�!. ....1 .. ...............•----------........----....or t .............................................
Locat' n-Address
h- ��.0... -----------------------•----- --........-----...---------.S-A.tLs ................
e Owner Address
T.......�.o........................ ..........................••-•-•--•••------•-....... ----•-----------............---••---
Installer Addre.ss
UType of Building Size Lot............................Sq. feet
�., Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder 014
Other—Type e of Building p ( ) — Cafeteria ( )c� YP g ---------------------------- No. of ersons---------------------------- Showers
Other fixtures .-O..&,t7........Ee LY-tnr�-.-----.�4--'4&A—t PAAYI%4_0.`�
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity.....--.....gallons Length................ Width................ Diameter--------.------- Depth................
x Disposal Trench—No..................... Width.................... Total Length.....................Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.........--..--..... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.......----..........--.
f14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
oa .--------•...............•-•----------•--•-••-•-----------•-----•-•-----•-••-------•-•------•-•••••..........................................................
Description of Soil........................................................................................................................................................................
W
U --•---•-•-••.......................................••-•••---••.....--•-----.......---•--•......•-----------•---•------•--•••--------•-•-------•---•••---...•---------•---•••--•----••...---••-•-••------
W
UNature of Repairs or Alterations—Answer when applicable...-- ....A-N.....PtD.D1�-t_�_OJV.P4j......44.6.0.
....-A 1.---. ....l,40...c1.g1.....
1-try-1�... t 1
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has 1be/en issued by the board of health. �`
Signed Y-rl_�/Lc 0................. ---
D
Application Approved By........... -----------------------•----------•---
Date
Application Disapproved for the following reaso :--------•-----••-------•----•-----•----------•-•----•------••----•--•-----------••----•---..Da------•---------
-•......--•---•-•-•-•-----------------••--••--•-•••-----••-••-•---•--.....•--•••••------••...----•---•--•-----•••....----------•-•------------•--•-----•----------------------••--••----------•...------
Date
PermitNo......................................................... Issued---------•------ --------------•--......---•--------
Date
..............................................................
PermitNo--------------------------------------------------------- Issued...........................................-----------
Date
THE COMMONWEALTH OF MAS SACHUSETTS
k11 .. 11 .
BOARD OF HEALTH
..........................................OF...................................................................................
Tertifiratr of Toutpfitturr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed o;'.:ReP air%
..........................................................................................................................
by........................ . .......
it
at........................4�- ......... 11-1:���........ *...... .......... ;44....................................
has been installed in accordanceljwitli the provisions WTI�-LF 5 of The State Sanitary Code as described in the
t ion Permit No.......,5?�.!!!j9s6;K9V>ated-----------
application for Disposal Works Construe .....;
..................w..............
THE ISSUANCE OF THIS";CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
ATI,M
SYSTEM WILL FUNCTION S SACTORT.'
h. .... .....ilct, Inspector .............................................................................
DATE.......................... .......... -------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................OF....................................................................y................
No..&�-.##�. ........................... FEE....,/.,r..........
Dispnoat Iforkii Tonotrurtion Wrmit
Permission is hereby granted .........
------------------------------------------------
to Construct or Repair granted
'.vage System
atNo----------------- 9e v"u e .........40V/ ------C------ /-,/....................................
/ Street
---lksonstruction Permit No Dated__________.____._..__._._.....__..._... .,.--as shown on the application for Disposal Wor
.................oar- of ---------------DATE---------------------------------------------------------- --------------
FORM 1255 A. M. SULKIN, INC., BOSTON N%
THE FOLLOWING
IS/ARE THE BEST
IMAGES FROM POOR
QUALITY ORIGINALS)
I M ^C&L
DATA
J ,
No......9 4_ 6 Fic$.....h.. ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
L.r. .!..... .....OF......'.`.. _`.......................................
Appliraitiun for BiupuuFal Workii Tnnutrnr#inn Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
........!..:..T_.....3-..................................................�...t ....•••-•.........................•---•--
Location-Address - . --•----••------•------•--•-•----••--•-•-•-.or Lot No.
.. .!C, r-
, n Owner Address
r ! ----------------A---—---------- -=---•-........
---------------------------- .........Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder kvd)
p`4 Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures ,.....S*e;,z4," '------------------------------
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width---------------- Diameter----------_..... Depth...._........_..
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No-_----------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-� Percolation Test Results Performed by.......................................................................... Date....-...................................
a
0_1 Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water.._.....................
rXq Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
-----------------------------------•---------------'= .........................•------...---------------------------------------- .... ----------------
O Description of Soil...................................................................
x •
U ......................................................................................................~............._......._......._..................................................................
W
UNature of Repairs or Alterations—Answer when ------------------ _________ -;_ r' ' ------:---___.:..
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed_ 1. r , t s l 1 ....._
to
Application Approved BY 0 �0&..I... ......���1 ��.....------.
Date
Application Disapproved for the following reaso . --.......••------••--•------------•---••-•-----•--•--•-••-•--•--------------------•--•---•---------------••....
L O'C`A'T ION SEWAGE PERMIT NO.
V I L L A C E
C'4-mforvi((�e-
INSTA/L,LER'S NAME A ADDRESS
�V V/-5
8 U I L D E R OR OWNER
DATE PERMIT ISSUED
DAT E COMPLIANCE ISSUED r�Z66
i
37
..A
C.
Fims..../. .................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
7o..�_.v....._..................O F........G.O.-R.r 1-5...719.61 r.................................
Appltrttttun for UWVuiia1 Works Tumitxnr#tun ramit,
Application is hereby made for a Permit to Construct (Y.) or Repair ( ) an Individual Sewage Disposal
System at: •n
Location Address or Lot No.
.......... \i Z fcti 7� �:d...........C0Akh.\........................... ......... .2....e Y:!Ax.wa QSa..---•. ' ..........................
Owner ddress
C.Cks— �2 e��o h................... 7•!.....rn- . ............ --.---...-
Installer is Address
Type of Building Size Lot.......................... fe
Dwelling—No. of Bedrooms........... .............................Expansion Attic ( ) Garbage Gr' r��
Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeter
Pa Other fixtures --------------- -----••---••••• .. .
W Design Flow......... per person per day. Total daily flow__.____..._.___ .a..�....._.......•..gallons.
WSeptic Tank—Liquid capacity%ftb.0_.gallons Length.6.'.�i'!_._ Width_.�/_.'1_S2_:!_- Diameter__-_____•-__---- Depth_..__. 6.._._.
x Disposal Trench—No..................... Width..................... Total Length..............__.... Total.leaching area....................sq. ft.
Seepage Pit No......... Diameter.........6Q...... Depth below inlet.........G........ Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1... ........minutes per inch Depth of Test Pit........LZ.... Depth to ground water_._/&Ikgn ef-
(i, Test Pit No. 2----rr2........minutes per inch Depth of Test Pit.......k2-:t..... Depth to ground water___ :�'�?
P4 •-•--•-••--------•--•--------•---••••.......-•-•-....•-••-.........•-•........................................
•------------------------------------
..........
O Description of Soil......M.OA!....Eae"y-----.. -A.......-•---••-•-----------------------------------------•------------------------------------...-•---------- ;
V •...................•-.............._..------•--•--............._.......••••••-•-•-------......_...........•--------•-•----••••-•--••---•••-•-•--••••-•-•----•-•-•-•-•-•---•••--•--......---••-•-----...
W
V 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health. l
.�
Application Approved By-•---Zflowing
..._....=`.... -•------•-- ----•--•�..... fir .....3._.
Date
Application Disapproved for reasons-------------------------------------••-----------•--•---------•---------------------•-••- ..D
---•--•--••-•--•-•--........•---------•-•-••-•-----•-----•-•••••---------•----•-•----------•-•---•---•-•-•-•--•-•--•-------••••--...------•••--••-•---•••------•---•---•--•-•-••----•--................
Date
PermitNo.......................................................... Issued.......................................................
Date
...................................................... Issue(L.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............I..............................OF..............................................................I.............I........
Tatifiratr of Toutpliatta
TIII ks Tr E FY, That the Individual Sewage Disposal System constructed"'or Repaired
by -----------------------------------------------------------------------
Installer
at........ ...... ........ .. .......a .... ................................................................................ ------- ------------has been installed in accordance with i the pr isio Of TITIZ 5 of The State Sanitary Coctv/as--deir?flbe in the
application for Disposal Works Constru Permit ................ date
------------------
THE ISSUANCE OF THIS CE;9 ICATE SHALL NOT BE CONSTRU��As X�,A-V* NTEEP17--THAT THE
SYSTEM WILL FUNCT19N S TISFACTORY.
DATE.......................... -------------------------------- Inspector---.. .... ......................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.....................................................................................
4...... ...... Ftf/14...................
14apolial IVu kii unotrudinul"Irrutit
Permission islhereby granted...If, .. ......................... ................ ............................................................
to Constructor RepaV( ) an Indivi. I a e
atNo. ........3-41....... ....... ........................................ .......... ...............
street
as shown on the application for Disposal Works Construc ermit No.................... ate "k -5................
-------------- ----- ----/..............................
DATE...../'C'. and of Health
---------------------------------------------- ---------------------------------
RM 1255 A. M. SULKIN, INC., BOSTON
No. ....E.IT.l�. Fxs a.................
THE COMMONWEALTH OF MASSACHUSETTS
-gyp^ BOAR® OF HEALTH
_. o-c—.-11---... - --.--......OF........ ..1�}..R..1.1.��.. ..( .................................
Applirativaa for Uhipati al Workii Tonutrurtiun amit
Application is hereby made for a Permit to Construct (>() or Repair ( ) an Individual Sewage Disposal
System at:
----.........`.#.. ........?.....�-,\..��... Q_n _.. _tl�............ ......•---...--------------------------....---------------------------.................-----------
L Ation-/Address f� or Lot No.
---------• -----------^S..t3-i).n.^................................ .........'`'—------ :i-�'l.fm:r..dt.a�'1 C- ----._�+..0 c...........................
` + \ Owner Address
�! la,vs .h�i x�ae _�o. ............................. ..........Tt z ... ..................................................
Installer Address
Type of Building Size Lot_......................... eet ;
U DwellingNo. of Bedrooms.......... .Expansion Attic Garba e Grin �2
pa,, Other—Type of Building ............................ No. of persons............................ Showers ( ) — Cafete )
Otherfixtures ---------------------------'--------------------------•--••---•--•--------•-••......•• ..............................................................
W Design Flow........a)3..(>-----------------------gallons per person per day. Total daily flow..._........._.°1_, ..7................gallons.
WSeptic Tank—Liquid capacity/bo-)---gallons Length 1!_¢1!.._. Width._2)4'!... Diameter................ Depth_.`!!.6''_..
x Disposal Trench—No.--_--.............. Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.......1------------ Diameter..........41...... Depth below inlet.........6.1...... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date-------------------�...................
,.a Test Pit No. 1............minutes per inch Depth of Test Pit-------j.Z..... Depth to ground water...14_, �,_1r..1-
GL, Test Pit No. 2....�; ......._minutes per inch Depth of Test Pit.......1.2.,....... Depth to ground water_-_IJ>_.lnr.�1_!.��
P4 •-•••--•••••-----•--•--•----••-•--••-------••---••••----•----••---•.......••-•---•.............................•--•••----•--••-••---•......-•----•-----.--•--
O Description of Soil------I&.A.....f;!•eeA, -=-----------------•.•.
x
w
VNature 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 TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
;V11owi:ng
� ...............................................
ate
Application Approved BY y; " N..... t
Application Disapproved for-thereasons------------------------------------------------------------------------- -------------------••---••---....------
--.........•---•-••••-••-•---•-•-•------•-••••-•-----•---•--••-•-•--•••••--••-••-•----••-.....-----••-•--•-••-•-••----••-•••-•••-••-••--••-•---•--••-•-••--•---•••-----•-•-••••--•------•-•---•----••---
Date
I
y
— C01%BI9\`��'EALTH OF MASSACHUSETTS
1�=
'Y t-
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE WINTER STREET. BOSTON MA 0210E (617) 292-5500
TRUDY CONE.
Secretan
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 39 Red.. Lillypond. Road., NameofOwnerJOseph Whelton
W. yannisport , MA Address of Owner:
Date of Inspection: ,t— — 95
Name of Inspector:(Please Print)Wm. E . Robinson
I am a DEP approved system inspector rsuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: Wm. E . Robinsoneptic Service
Mailing Address: _P.O . Box 1089, Centerville , MA
Telephone Number: T8 7 7 h
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewagedisposal systems. The system:
_LIOasses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: irtj Date: e
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within thirty (30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the 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.
n � d
NOTES AND COMMENTSo
r�E+
� to
0
�-
��AY 2 1999 t-1
TrnMr OF Mn Ake
revised 9/2/98 Page Iof11
\ iW Panted on Recycled Paper
' V
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A S� y
CERTIFICATION (continued)
'rop"Address: 39 Red. Lillypond. Road., W. Hyannisport
',)weer: Joseph Whelton
Date of Inspection:
INSPECTION SUMMARY: Check�A,y B, C, of D:
A. SYS PASSES: �V
1 have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
t
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.
Indicat yes, no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined",sexplain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (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 pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health).
broken pipe(s) 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 pipe(s). The system will pass
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
Ile
revised 9/2/98 Page 2ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 39 Red. Lillypond. Road., W. Hyannisport , MA
Owrber- Joseph Whelton
Date of Ins on: J-3--nQ
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 the
public health, safety and the environment.
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 THE PUBLIC HEALTH AND 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 or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
3) OTHER
revised 9/2/98 Page 3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
M1
PART A
CERTIFICATION (continued)
Property Address: 39 Red. Lillypond. Road., W. Hyanriisport, MA
Owner: . Joseph Whpelton
Date of Inspection: '3
D. SYSTEM FAILS:
You m st indicate either "Yes" or "No to each of the following:
have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes o
Backup of sewage into facility or system component due to an overloaded orclogged 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.
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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a 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 I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for
,coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LAR E SYSTEM FAILS:
You mus indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The o ner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office f the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Prop"Address: 39 Red, Lillypond. Road., W. Hyannisport , NIA
Owner: Joseph Whelton
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 1
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 N/A.
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 Soil 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)
[15.302(3)(b)1
_ The facility owner(and occupants,if different from owner) were provided with information on the proper maintenaucco.of
SubSurface Disposal Systems.
revised 9/2/98 Page 9ofII
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
$rop"Address: 39 Red. Lillypond. Road., W. Hyannisport , MA
Owner: Joseph Whelton
Date of Inspection: 3-3—9 5
FLOW CONDITIONS
RESIDENTIAL:
Design flow:36 o g.p.d.!bedroom.
Number of bedrooms 1 esign):, Number of bedrooms (actual
Total DESIGN flow ,0
Number of current residents: etl
Garbage grinder lyes or no): C
Laundry Iseparate system) (yes or no):/ If yes, separate.inspection required
Laundry system inspected. (yes or no)
Seasonal use (yes or no):I&IA 1998 106, 000 gal.
Water meter readings, if available (last two year's usage(gpd):
Sump Pump(yes or no):/V 1997 135, 000 gal.
Last date of occupancy:
COMMERCIALIINDUSTRIAL:
Typ of establishment:
Desi flow: qpd ( Based on 15.203)
Basis f design flow
Greas trap present: (yes or no)_
Indust 'al Waste Holding Tank present: (yes or no)_
Non-s itary waste discharged to the Title 5 system: (yes or no)_
Water eter readings, if available:
Last d to of occupancy:
O R:(Describe)
Last to of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System ll��d as part of inspection: (yes or no)jj4_2$
If yes, volume pumped: gallons
Reason for pumping:
TYPE 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)
I/A 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: o�lS S
Sewage odors detected when arriving at the site: (yes or no),� d
revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'rop"Address:39 Red. Lillypond. Road; W. Hyannisport , MA
Owner: Joseph Whelton
Date of Inspection:
6 LDING SEWER:
(L-c to on site plan)
Dept below grade:_
Mater at of construction:_cast iron_40 PVC_other(explain)
Dista ce from private water supply well or suction line
Diam ter
Corn ants: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan)
,r
Depth below grade?- 6
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:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or-baffle:3O,
Scum thickness:, A.
, r
Distance from top of scum to top of outlet tee or baffle: A. ' I
Distance from bottom of scum to bottom of outlet tee or baffler
How dimensions were determined: O
'comments:
(recommendation for pumping, condition of inland ou�let tees or baffles, d pth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.) jD�-� C /��') �.& 7.4— 1P Id L G`
G SE TRAP:
(local on site plan)
Depth elow grade:_
Materia of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensi s:
Scum thi kness:
Distance rom top of scum to top of outlet tee or baffle:
Distance rom bottom of scum to bottom of outlet tee or baffle:
Date of l t pumping:
Commen s:
(recom endation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidenc of leakage,etc.)
revised 9/2/98 Page 7of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION Icontirwed)
'rop"Address: 39 Red. Lillypond. Road., W. Hyannisport , MA
Owner: Joseph .Whelton
Date of Inspection: 3�d
TIG TOR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(local on site plan)
Depth elow grade:_
Mated I of construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dime ions:
Capa ions:
gallons
Des. flow: gallons/day
Alar present
Alar level: Alarm in working order: Yes_ No_
Dat of previous pumping:
Co ments:
(c dition.of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:_
(locate on site plan)
Depth of liquid level above outlet invert:
Comments:
(note if level and distribution is equal, evid ce of solids carryover, evidence of leakage into or out of box, etc.) -
PUM CHAMBER:_
(locat on site plan)
Pump in working order:(Yes or No)
Alarm in working order(Yes or No)
Com ants:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
revised 9/2/98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
a PART C
SYSTEM INFORMATION(continued)
Nop"Address: 39 Red. Lillypond. Road., W. Hy.annisport , MA
)Wner: Joseph Whelton
Jate 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)
�er�l
revised 9/2/98 Page 10ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
'rop"Address: 39 Red. Lillypond. Road , W. Hyann sport , MA
Owrwf: Joseph Whelton
Date of Inspection: °'—3,_Q 9
SOIL ABSORPTION SYSTEM(SAS):l/
(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: f
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},ydraulic failure, level of onding, dam soil, condition of ve etati n, etc.)
/6 d b �b c,aCr / 9 Iji, �1
SPOOLS:_
(loc to on site plan)
Num er and configuration:
Dept -top of liquid to inlet invert:
Depth f solids layer:
)epth f scum layer:
Dimens ons of cesspool:
Materia of construction:
Indicati n of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comme ts:
(note c ndition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRI _
(loc to on site plan)
Mater Is of construction: Dimensions:
Depth f solids:
Comm nts:
(note ondition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
ropertyAddress�9 Red. Lillypond. Road., W. Hyannisport , MA
Owner: Joseph Whellton
Date of Inspection:
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater/s Feet
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
OObserved 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
ti
Describe how you established the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page 11of11
Z."�03 498 881
US Postal Service
Receipt for Certified Mail
No Insurance Coverage Provided.
Do not qke for International Mail See reverse
Sent
&Numb
P ce,S IP
Postage $
Certified Fee
Special Delivery Fee
Restricted Delivery Fee
0
Retum Receipt Showing to
Whom&Date Delivered
Return Receipt Showing to Whom,
Date,&Addressee's Address
0 TOTAL Postage&Fees $
ch Postmark or Date I
Stick postage stamps to article to cover First-Class postage,certified mail fee,and
charges for any selected optional services(See front).
1. If you want this receipt postmarked,stick the gummed stub to the right of the return
address leaving the receipt attached, and present the article at a post office service
window or hand it to your rural carrier(no extra charge).
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the fY
return address of the article,date,detach,and retain the receipt,and mail the article.
LO
3. If you want a return receipt,write the certified mail number and your name and address rn .
on a return receipt card,Form 3811,and attach it to the front of the article by means of the
gummed ends if space permits. Otherwise,affix to back of article. Endorse front of article n
RETURN RECEIPT REQUESTED adjacent to the number. I Q
4. If you want delivery restricted to the addressee, or to an authorized agent of the O
O
addressee,endorse RESTRICTED DELIVERY on the front of the article. O
ch
5. Enter fees for the services requested in the appropriate spaces on the front of this .E
receipt. If return receipt is requested,check the applicable blocks in item 1 of Form 3811.
6. Save this receipt and present it if you make an inquiry. 102595-97-B-0145 a
m SENDER:
'o ■Complete items 1 and/or 2 for additional services. I also wish to receive the
m ■Complete items 3,4a,and 4b. following services(for an
4) ■Print your name and address on the reverse of this form so that we can return this extra fee):
card to you. ai
■Attach this form to the front of the mailpieos,or on the back if space does not 1. ❑ Addressee's Address 2
d permit.
■Write'Retum Receipt Requested'on the mailpiece below the article number. 2, ❑ Restricted Delivery N
■The Return Receipt will show to whom the article was delivered and the date ..
delivered. Consult postmaster for fee.
0
3.Article Address d to: 4a.Article Number i
/41
E 4b.Service Type
u CC (� ❑ Registered it Certified ¢
of
y j + ❑ Express Mail ❑ Insured
❑ Return Receipt for Merchandise ❑ COD
a7.Date of�glpr�
0.
5 5.Received By:(Print Name) 8.Addressee's Address(Only if requested
W and fee is paid) t
6.Signa Addressee Ag
0. X
PS Form 3811, December 1964 102595-97-13-0179 Domestic Return Receipt
UNITED STATES POSTAL SERVICE First-Class Mail
Postage&Fees Paid
USPS
Permit No.G-10 '
• Print your name, address, and ZIP Code in this box•
Public Health DIVISION
Town of Barnstable
PO Box 534
Hyannis, Massachusetle OW
Fax(508)775-3344
Phone(508)790-6265
o �Hb'BBS&W R ENINC 1�A F/�THE QIIM�ON�E�q�LTHO A'S.SAACH�USETTS� rb
BOARD OF HEALTH /y��L��GcLIING
DEP�ARNf�
c�'�_ s°>'` *�/'✓ / //j� / V fAD,D7ESS0 'Iy!(IfVir
f !J TELEPHONEf U—fj" 01
Address r .. r O r ->Oc uo pant
Floor •�� l�o{�'� ?(IfAts . rum N.bly 1 IZ
No.of Habitable Rooms No.Sleeping Rooms
�� J No.dwelling or rooming units No.Stories
G^ - n'Jj� Name and address of owner e / , Ito }� G
WHE�- I r�O !tr �merks� Re/►g vjp
�J✓ YARD Out Bld s.: P6e�cesa ��/
Garbage and Rubbish
Containers:
Drainage
Infestation Rats or other:
STRUCTURE_EXT., Steps,Stairs, Porches:
Dual Egress:and Obst'n.:
❑ B ❑ F ❑ M Doors,Windows:
Roof
Gutters, Drains:
Walls:
Foundation:
Chimne :
BASEMENT Gen.Sanitation:
Dampness:
Stairs:
Lighting:
STRUCTURE INT. Hall,Stairway:
Obst'n.:
Hall, Floor,Wall,Ceilin
Hall Li htin :
Hall Windows:
HEATING Chimne s:
Central ❑ Y ❑ N Equip. Repair
TYPE: Stacks, Flues,Vents: f`
PLUMBING: Supply Line:
❑ MS ❑ ST ❑ P Waste Line:
H.W.Tanks Safety and Vent(s)
ELECTRICAL Panels, Meters,Cir.: _ o
❑ 110 ❑ 220 Fusing,Grnd.: pr r7k./C - AND
AMP: Gen.Cond. Distrib. Box:
` Gen. Basement Wiring: w►�✓ is • <
DWELLING UNIT
Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks
Kitchen
Bathroom
Pantry
Den
Livina Room
Bedroom 1
Bedroom 2
Bedroom 3
Bedroom 4
Hot Water Facil. Sup.Ten.,Gas,Oil, Elect.:
Stacks,Flues,Vents,Safeties:
Kitchen Facilities Sink
Stove
Bathing,Toilet Facil. G Vent., Plumb.,Sanit'n.:
Wash Basin,Shower or Tub:
Infestation Rats, Mice, Roaches or Other:
E ress Dual and Obst'n:
General Building Posted
Locks on Doors:
ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH
MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL—BEING OF THE
OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE
AUTHORIZED INSPECTOR.(See Over)
"THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND
PENALTIES OF PERJURY."
� aa ,A
INSPECTOR (J ; n f( TITLE
DATE A`'�L' TIME • 7P MTHENEXTSCHED' EDREINSPECTION
P.M.
410.750: Conditions Deemed to Endanger or Impair Health or Safety
The following conditions, when found to exist in residential premises,
shall be deemed conditions which may endanger or impair the health, or safety
and well-being of a person or persons occupying the premises. This listing `
is composed of these items which are deemed to always have the potential to
endanger or materially impair the'health or safety, and well-being of the
occupants or the public. Because Chapter II, 105 CMR 410.000 through 410.499
state minimum requirements of fitness for human habitation, any violation has
the potential to fall within. this category in any given situation but may not
do so in every case and therefore cannot be included in this listing. Failure
to include shall in no way be construed as.a determination that other,,,
violations may not be found to fall within this category. Nor shall failure
to include affect the duty of the local health-official to order repair or
correction of the violation(s) pursuant to 410 CMR 410.830 through 410.833
nor-shall it affect the legal obligation of the person to whom the order .is
issued to comply with such order.
-(A) Failure to provide a supply of water sufficient in quantity, pressure
- eand temperature, both hot and cold, to meet the ordinary needs of the occupant
-' in accordance with 105 CMR 410.180 and 410.190 fora period of 24 hours or
longer. -
(B) ._Failure to provide heat as required by 105 CMR 410.201 or improper
venting or use.of a space heater. or water heater as prohibited by 105 CMR
410.200(B) and 410.202.
- (C) Shut-off and/or failure to restore electricity or gas.
(D). .-Failure to supply the electrical facilities required by 105 CMR 410.250(B),
410.251(A); 410.253(A); 410.253(B) and the lighting in common 'area required
- - by-105-CMR 410.254. -
_'(E) . Failure.-to provide a safe supply of water.
(F) Failure to provide a toilet and maintain a sewage .system in operable
condition as required by 105 CMR 410.150(A)(1) and 410.300.
"'(G) Failure to provide adequate exits, or the obstruction of any exit,
,- passageway-or common area caused by an object, including garbage or trash,
which prevents egress in case of an emergency 105 CMR 410.450 and 410.451. `
`(H) ..Failure to comply with the security requirements of 105 CMR 4110.480(D).
, `(I) Failure to comply with any provisions of 105 CMR .410.600 through 410.6.02
r ;:nLich. results in any accumulation of garbage, rubbish, filth or other causes
':'i sickness which may provide a food source or harborage for rodents, insects _
-ior other pests or otherwise contribute to accidents or to the creation or
spread of disease.
(J) The presence of lead-based paint on a dwelling or dwelling unit in
.viblation of the Massachusetts Department of Public Health Regualtions for
,.Lead Poisoning Prevention and Control 105 CMR 460.000.
=(A) !oof,'foundation, -or other structural defects that may expose the ._
_ 'Occupant or anyone else to fire, burns, shock, accident or other danger,s.or
f*Att dent to health =or dafety. _
i
- (L) Failure to install electrical, plumbing, heating and gas-burning
i facilities in accordance with accepted -plumbing, heating, gas-fitting and
r electrical wiring standards or failure to maintain such facilities as-
are required by 105 CMR 410.351 and 410.352 so as to expose the occupant
, or_ anyone else to fire, burns, shock, accident or other danger or impairment .
`to:health or, safety. .
Any of the following conditions which remain uncorrected for a period
of five or more days following- the notice to or. knowledge of the owner
of said'condition or conditions:
•(;.)-' -lack of a kitchen sink of sufficient size and capacity for
washing dishes and kitchen utensils or lack of a. stove and oven ,
or-any defect that renders'either operable.
I-- - - - (2) -failure to.provide a washbasin and a shower or bathtub as required
in 105 CMR 410.150(A)(2) and 410.150(A)(3) and any defect which
renders them inoperable. -
(3) any defect in the electrical, plumbing, or heating system•which makes
such system or any- part thereof in violation of generally accepted .
plumbing heating,, gae-fitting, or electrical wiring standards
that do not create an immediate hazard.
(r) failure to maintain a safe handrail or .protective railing for every
stairway, porch balcony, roof or similar place as required by
105 CMR 410.503(A) and 410.503(B).
(5) failure"to eliminate rodents, cockroaches, insect infestations and
other pests as required by 105 CMR 410.550.
(N) Amy other violation of Chapter II not enumerated in 105 CMR 410.750(A) -
through (M) shall be deemed to be a condition which may endanger or materially
lapst the health or safer and well-being of an occupant upon the failure of
.i Y
the owner to remedy said condition within the time.so ordered by the board
of health..
i
PAR ] Real Estate System - General Property Inquiry] Help [ ]
Parcel Id: 227 045- - Account No: 137514 Parent :
Location: 39 RED LILY POND CRAIG Neighborhood: 55AC Fire Dist : CO
Devel Lot : 6 & 7 BLOCK C Lot Size : .46 Acres
Current Own: WHELTON, JOSEPH A & State Class : 101
WHELTON, PATRICIA M No. Bldgs : 1 Area: 1680
121 BRIARCLIFF LANE Year Added:
HOLLISTON MA 1746
Deed Date : 110189 Reference: 6945/341
January 1st : WHELTON, JOSEPH A & Deed MMDD: 1189 Deed Ref : 6945/341
Comments :
Values : Land: 40000 Buildings : 104200 Extra Features :
Road System: 39 Index: 1355 (RED LILY POND ROAD ) Frntg: 100
Index: ( ) Frntg:
Control Info: Last Auto Upd: 050695 Status : C Last TACS Update : 060890
Land Reviewed By: Date : 0000 Bldgs Reviewed By: Date : 0000
Tax Title : Account : Taken: Account Status : Hold Status :
Cancel [ ]
Press XMT for more data
Next screen [PAR ] Action [ ]
Owners Name [ ]
Road Index [ ] Road Name [ ]
Parcel Number [227] [046] [ ] [ ] [ ]
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