HomeMy WebLinkAbout0028 ALICIA ROAD - Health f�&Alicia Road
Hyannis
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TOWN OF BARNSTABLE
L.00r%TION QA O SEWAGE # ,260a- 0 a a
'VILLAGE [W i-JW i 5 ASSESSOR'S MAP & LOT a6 7
INSTALLER'S NAME& PHONE NO. RGV'r-SSOO -'rGPVV C_ 775—T 7 7(o
SEPTIC TANK CAPACITY 1 6O y
LEACHING FACILITY: (type) �2 DOW(- ((S (size) 1.3x2- ,�'6-S
NO. OF BEDROOMS 3
BUILDER OR OWNER GEo�►F Mq DDO>
PERMITDATE:6QA COMPLIANCE DATE: S�f Oa
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is required for Hyannis Ma. 02601 4/3/2009
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms the
computer,
r,use 1. Inspector:
only the tab key
to"move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
r� t P.O.Box 763
Company Address
Centerville Ma. 02632
" City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes' ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
i
4/3/2009
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
&A __�:
and copies sent to the buyer,-if applicable, and the approving authority.,
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
Lo
15ins•09108 Title 5 Official Inspection Form:Sub dace Sewage.Disposal System-Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is required for Hyannis Ma. 02601 4/3/2009
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
I
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
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):
l5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is required for Hyannis Ma. 02601 4/3/2009
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N . ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form Not for Voluntary Assessments
M 28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is required for Hyannis Ma. 02601 4/3/2009
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 coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility.or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w„ 28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is required for Hyannis Ma. 02601 4/3/2009
every 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 ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to.the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered"yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
F v Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is required for Hyannis Ma 02601 4/3/2009
every page. Cityrrown 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:
ti
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑. ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is required for Hyannis Ma. 02601 4/3/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
The septic system consists of a 1000 gallon septic tank,distribution box and two 500 gallon drywells.
Number of current residents: unknown
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required) ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonaluse? ❑ Yes ® No
000,:105
Water meter readings, if available (last 2 years usage(gpd)): 2002008: 05 00
Detail:
2008:287 gpd 2007:244 gpd
Sump pump? ❑ Yes ® No
Last date of occupancy: 4/3/2009
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-09108 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0
28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is required for Hyannis Ma. 02601 4/3/2009
every 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):
15ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is required for Hyannis -Ma. 02601 4/3/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
New leaching installed in 2002
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 26"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight:No evidence of Ieakage.System vented through the house vents.
Septic Tank(locate on site plan):
2711
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000
Sludge depth:
5"
t5ins-09/08 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
M 28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is Hyannis Ma. 02601 4/3/2009
required for y ,
every 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
27"
Scum thickness
4"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
8"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump septic tank every two years.lnlet and outlet tees are in place.No evidence of Ieakage.Tank
appears to be structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-09108 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
M 28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is required for Hyannis Ma. 02601 4/3/2009
every page. City/Town 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
15ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form = Not for Voluntary Assessments
i
28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is required for Hyannis Ma. 02601 4/3/2009
every page. Cityrrown 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 No
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.):
Box is Ievel.Box has one outlet lateral.No evidence of solids carryover.No evidence of leakage into or
out of box. .
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 cf 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is required for Hyannis, Ma. 02601 4/3/2009
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 2-500 gl.
❑ 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.):
Sandy dry soil.No signs of hydraulic failure.Chambers were 8" below invert at time of inspection with
no stain line any higher.
art
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-09108 Title 5 Official Inspection Forth: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
28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is required for Hyannis Ma. 02601 4/3/2009
every page. Cityrrown 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.):
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name .
information is required for Hyannis Ma. 02601 4/3/2009
every 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: Bottom of leaching 23.1'feet
Please indicate all methods used to determine the high ground water elevation:
I
❑ 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:
As-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USED:USGS Observation Well Data.USED:Technical Bulletin 92-000-01 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please.see Report Completeness Checklist on next page.
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
28 Alicia Rd.
Property Address
Francisco Macedo
Owner Owner's Name
information is required for Hyannis Ma. 02601 4/3/2009
every 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
I
t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17
�hX FI�
Also, you are. reminded that any major renovations, remodeling, additions; and/or
changes to menus or changes of equipment requires review by Health Division staff prior
to.the changes/renovations. Please submit proposed plans. of any kitchen remodeling to
this Office before any construction work begins.
If you should have,any questions,please telephone the Health Division at 508-862-4644.
PER ORDER OF THE BOARD OF HEALTH.
i
Wayne Miller,M.D.
Sumner Kaufman, M.S.P.H.
Paul Canniff,D.M.D.
gAtouchless faucets for restaurants.doc
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COMMONWEALTH OF MMSACHUSE17S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS .
DEPARTMENT OF ENVIRONMENTAL PROTECTION
II
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION r
Property Address: 28 Alicia Road
Hyannis j
Owner's Name: George Maddox 7.3
9 0
Owner's Address:
Date of Inspection:
Name of Inspector:(please print) W i 11 i am E_ . Robinson sr. '
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1 089
Centerville, MA
Telephone Number: (508) 775-8776
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Sec 'on 15.340 of Title 5(310 ChIR 15.000). The system:
asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
4 Inspector's Signature: _1�2 Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health-or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater;the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be scot to the system owner and copies':scnt to the buyer,if applicable,and the approving
authority.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same-or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 28 Alicia Road
Hyannis
Owner. George Maddox
Date of Inspection: `2.. —D
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sythavc
sses:
ot 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. Syste Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.Th system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,n or not determined(Y,N,ND)in the for the following statements.If"not determined"please
explain.
The sept c tank is metal and over 20 years old`or the septic tank(whether metal or not)is structurally
unsound,exhib substantial infiltration or exilltration or tank failure is imminent_System will pass inspection if the
existing tank is eplaced 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 a tank is less than 20 years old is available.
ND explain:
Obsery tion of sewage backup or break out or high static water level in the distribution box due to-broken or
obstructed pip (s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval of B ard of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The s stem required pumping more than 4 times a year due to broken or obsmxted pipe(s).The system will
pass inspectio if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 28 Alicia Road
Hyannis
Owner: George .Maddox
Date of Inspection: -p
G 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 fai ' g to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety,and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier;if any)determines that the
s tem 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 front a ;
private water supply well" Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory, for,coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
Other:
3
Page 4 of I I .
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 28 Alicia Road
Hyannis
i
Owner: George Maddox
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You ust 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 bc.x 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'h day flow
Required pumping more than 4 times in the last year.NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS.cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within I OO.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 Net front a private water
supply well with no acceptable water quality analysis.(This system passes if the well water analysis,
performed at a DEP certified laboratory.,for coliform bacteria and volatile organic compounds
indicates that the well is free.from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure.criteria
are triggered.A copy of(he analysis must be attached to (his form.)
(YeslNo)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:
T be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gj id.
Y u must indicate either"yes"or"no"to each of the following:
(I lie following criteria apply to large systems in addition to the criteria above)
yes no
_ the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a s�face drinking water supply -
the system is located in�a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
If u have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"ye "in Section D above the large system has faylcd.The ow�ta ar operator of arty large system considered a
Sig
ificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
I5. 04.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 28 .Alicia Road
Hyannis
Owner: George Maddox
Date of Inspection:_4)_jg—G
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
_ _yPumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
v _ 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?
v_ 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?
'1/ _ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes .no
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CIAR 15.302(3)(b)J
5
Page 6 of I
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 28 Alicia Road
Hyannis
Owner: George Maddox
Date of inspection: —' G
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):.., Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms):
Number of current residents:_
Does residence have a garbage grinder(yes or na): sL
Is laundry on a separate sewage system(yes or no): &0 [if yes separate inspection required)
Laundry system inspected(yes or no):/�O
Seasonal use:(yes or no):'i O
Water meter readings,if available(last 2 years usage(gpd)): 0 4/0 5 — 76, 500
Sump pump(yes or no): — 84, 750
Last date of occupancy:
COMMERCIA NDUSTRIAL
Type of establis ent:
Design flow(b ed on 310 CMR 15.203): gpd
Basis of desi ow(seats/persons/sgft,etc.):
Grease trap p sent(yes or no):_
Industrial w to holding tank present(yes or no):—
Non-;ani waste discharged to the Title 5 system(yes or no):_
Water me r readings,if available:
Last date f occupancy/use:
OTH (describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of tfie inspection(yes or no): O a
If yes,volume pumped:_gallons--H6w was quantity pumped determined?
Reason for pumping:
TYeP IF SYSTEM
1p�eptic 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
ob_tained from system owner) -
-Tight tank Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if known)and source of informatio
Were sewage odors detected when arriving at the site(yes or no):Lv
6
• ]'age 7 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARV ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SVSTEM INSPECTION F010.1
PAItT C
SYSTEM INFORMATION (continued)
Properly Address: 28 Alicia Road
Hyannis
Owner: Geor a Maddox
Date or lnspec(ion: �O1
BUILDING SEWER(lot a on site pla»)
Dcpgt below grade:
Materials of construe ' n:_cast iron _40 PVC_ogler(explaut):
Distance front priv a water supply well or suction lute:
Comments(on c dition of juutts,vatting,cvidcncc of leakage,etc.):
SEPTIC TANK:_ locate on site plan)
rr
Depth below grade:_ � �
Material of construction: �'cuncrete_metal fiberglass�,vlyegrylene
_othcr(explain)
If tank is metal list age:— Is age confinned•by a Certificate of Compliance(yes or no):' (attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet Ice or battle: s�
Scut thickness: J".2, 11 1
Distance from top of scum to top of outlet Ice or baffle:
Distance Gom botlout of scull,to bottom of,o4ct ice or battle: /3,a
I low were dimensions determined: C-0—
Com,nents(on pumping recommendations, inlet and outlet tee or battle condition,structural integrity,liquid levels
as related to outlet invert,evidence of Icak ge,etc.)) ti
GREASE TRAP:_(locate on site plan)
t(onpuniping
elow grade:_al of cons ction:_concrete_metal_fiberglass 1iol)•egt)•Iene other
n):sions:hicknc s:e Go t lop of stunt to top of outlet Icc or baffle:
ce fr in bottom of scum to bottun,ofoutlet Icc or battle:
f I t pumping:e is(on pumping reconttuendations,utlet and outlet Icc or baffle conditio:, structural integrity,liquid levels
d to outlet invert,c%-idence of leakage,e(c.):
7
Page 8 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEIVAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORII-IATION(continued)
Property Address: 28 .Alicia Road
Hyannis
Owner: George Maddox
Dale or Inspcctloo: — "6
TICIIT or HOLD TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grad
Material of cons) ction:_concrete_metal_fiberglass_pulyethylent othet(explaut):
Dimensions:
Capacity: gallons
Design Flow• gallonstday
Alarm presc t(yes or no):
Alarm leve : Alarm in working order(ycs or no):_
Date of I i pumping:
Conunents(condition of alarm and float switches,etc.):
DISTIIlUUT10N BOX:_ if present must be opcncd)(locate on site plan)
)
Depth of liquid level above outlet invert:
Conunents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,ctc.):
PUMP CHAMBER: (locate on site plan)
Pumps in working der(yes or no):
Alarms in workin order(yes or no): —
Conunents(not condition of pump chamber,condition of pumps and appurtenances,e(c.):
Page 9 of 11
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Add ress: 28 Alicia Road
Hyannis
Owner: George Maddox
Date of Inspection: — �•-
SOIL ABSORPTION SYSTEM(SAS): �60 (e on site plan,excavation not required)
If SAS not located explain why:
Type
le hing pits,number:_
eaching 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.):
��7 c G
CESSPOO/da
esspool must be pumped as part of inspection)(locate on site plan)
Number anation:
Depth—to to inlet invert:
Depth of s :Depth of s .Dimensionool:Materials oction:Indicationwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials construction: ,
Dimensi s: -
Depth solids:
Co nts(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
r
9
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 28 Alicia Road
Hyannis
Owner: George ,Maddox
Date of Inspection: -'O
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
' d
/ J
� s3
13
10
Page 11 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 28 Alicia Road
Hyannis
Owner. George Maddox
Date,of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells X
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Pbtained from system design plans on record-If checked,date of design plan reviewed:
yObserved site(abutting property/observation hole within ISO feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You myst descyibe ho y u established the high ground water elevation:
i
11
No.'
A00Lo
Fee 5 0 t
THE COMMONWEALTH OF MASSACHUSETTS Enteted.in computer: +/
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
X2pplication for Mood 6potem Conotruction Vertu
Application for a Permit to Construct( . )Repair(X)Upgrade( )Abandon( ) D Complete System D Individual Components
ca' n Address or Lot No. Owner's Name,Address and Tel.No.
Ae 0 s MA
Ps' ap�igtia Rd. , Hyannis . George Maddox
o
Installer's ame,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic service Dan Johnson
P O Box 1089, Centerville 804 Main St. , Osterville
G" pe of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building P c n i ri P n t j,-LL No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets IRevision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil, med—coarse sand
Nature of Repairs or Alterations(Answer when applicable) Rep lace failed s a s with 2
dry wells 25 'L X 121W X 2 H overall.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Bo d o ealth.
Signed Date S
S
Application Approved by, O Date
Application Disapproved or the following reaso
r
Permit No. Date Issued
—
71' , - ' �f"#' ..27,E !-.,' i i-#� .•a:_ LL._. y=1`��"`1 �..». �sx. r,.*+w+ (I. ._. wwv..;�
lfoAtoj Fee $50
a,b THEI COMMONWEALTH OF MASSACHUSETTS :.EQ end in computer:
Yes
` PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE. MASSACHUSETTS ;r
U,
ZippCication for 30i.5pooar *pgtem Congtruction Permit
=-
R ation for a Permit to Construct( . )Rep(}{)Upgrade( )Abandon( ) ❑Complete System E)Individual Components
'kat�6'n Address or Lot'No. Owner's Nam
e,Address and Tel.No.
Assessor'-sIvl'ap1.g�1 a Rd. , Hyannis George\ Maddox
cia— —7
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic service Dan Johnson
P O Box 1089, Centerville 804 Main St. , Osterville
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
K Other Type of Buildingte- o31dPnt-1 a 1 No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 330 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date :3
Title
Size of Septic Tank Type of S.A.S.
Description of Soil: med—coarse sand
Nature of Repairs or Alterations(Answer when applicable) Replace failed sas with 2
dry wells e25'L X 12'W X 2 H overall.
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system "
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this Bo Lrd3pmealth.
Signed o Date OP—
Application Approved by �' Date
Application Disapproved or the following reaso
Permit No. Date Issued ,
THE COMMONWEALTH OF MASSACHUSETTS
Maddox BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( X )Upgraded( )
Abandoned ( )b Wm. E. Robinson Septic service
at , , Alii<}�a R . , Hyannis s beVe—d
nstructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No
Installer Wm. E. Robinson Sr. Designer Dan Johnson
The issuance of this p rmit shall not be construed as a guarantee that the sys _ wil function a esigned.
Date S `�u 7u a Inspector 1 .4/
/4
No. D � �� .---------—--———.—.—_— � Fee T,5 n _
Maddox THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE,, MASSACHUSETTS
lwigpogal *pgtem Con.5truction Permit
Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( )
System located at 28 Al i t i a Rr1
and as described in the above Application for.Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction muo c� et d w"t in three years of the date of this t. ' /,Z
Date: Approved by
5MI0l
NOTICE: This Form Is To Be Used'For the Repair Of Failed
Septic Systems Only.
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION
FORM
hereby certify that the engineered plan signed by me
dated , concerning the property located at
/LO'g-'a meets all of the
following criteria: —
This failed system is connected to a residential dwelling only. There are no
commercial or business uses associated with the dwelling.
The soil is classified as CLASS I and the percolation raie is less than or equal to 5
minutes per inch. The applicant may use historical data to conclude this fact or may
conduct preliminary tests at the site without a health agent present.
• There is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The bottom of the proposed leaching facility will not be located less than fourteen
(14) feet above the maximum adjusted groundwater table elevation. [Adjust the
groundwater table using the Frimptor method when applicable)
Please complete the following:
A) Top of Ground Surface elevation (using GIS information)
B) G.W. Elevation +adjustment for high G.W.S'(�`411') - 3-6
DIFFERENCE BETWEEN-A and B !Z 'A
/ Qcti-r-I AL_ �D
SIGNED : DATE:
NOTICE
Based upon the above information, a repair permit will be issued for bedrooms
maximum. No additional bedrooms are authorised in the future-without engineered
septic system plans. a
q:heilth folder.percexmp
s
TOWN OF BARNSTABLE
ON g' ffiM Q,,A Q SEWAGE # 260a-- J a a
VILLAGE IIV614w S ASSESSOR'S MAP & LOT
INSTALLER'S NAME& PHONE NO. R%Z'Vf3sao Seic, 775-'777�0 .
SEPTIC TANK CAPACITY _T 0 y
LEACHING FACILITY: (type) (size) i 3 T 2-
NO. OF BEDROOMS 3
BUILDER OR OWNER CrEO!?:!�P MAiD"Da>z—
PERMITDATE:`h q k COMPLIANCE DATE:f O.a
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water-Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
6ACkC,
a
may,
r
Yy� 0
i
10.. :1... _ -•• Fnx....... .......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD PF HEALTH
............O F...... .
Appliration for Disposal lVarku Tonotrurtinn,Pumit
Application is hereby-made for a Permit to Construct (/--ror Repair ( ) an Individual Sewage Disposal
- Syst at• d '
••�.... ._ ..___i ....Ad, �__-.z Q.�_... -�--�-•-�---------------------------
L do Address or Lot�N,
• 1-•••-•----- a� 0 ---------•---••----___----•------
Owne Address
(� A
Instal le
Address a
Q Type of Build' Size Lot../_l_.[�2. ...Sq. feet
Dwelling No. of Bedrooms--------a. .........................Expansion Attic ( ) G bage Grinder ( )
P4 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
a' Other fixtures,.__.._-
W Design Flow_____________________________ _____ gallons per person per day. Total daily flow________________,______________-___---------gallons.
WSeptic Tank(—.Liquid capacit��_gallons Length-------------_- Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width__________ .. T t� en tli.... _...__ Total leaching area....................sq. ft.
3 Seepage Pit No.____/_____________ Diameter_� .. e o 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.................... Depth to ground water........................
(14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water------------------------
P4 •••-•-----•-----------------------••-- -)--•--------------- ....... -•-- --•-------•-••------•----------------•-----•------
O Description of Soil...............--........................ •-• 1
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 Article YI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b i ed by e and of h lth.
Signed. - ...... •--
Date oe
Application Approved By............--- .... -----• ----•-- LZ -- - -----=• �� Vic ' ------
D e
Application Disapproved for the following reasons_________________________________________ ______________________________________________________________________
-------•----•--_----••--•------•--•----•---•----••---------=-•---------------•-••-••--•••=--•-----------..._---•----•------•-•---•-••-----------•-----•--•-----------.._.__.._._.._...._•------•-----•---
Date
PermitNo......................................................... Issued........................................................
Date
._..._-------._"------------------------------------------------------- ------------------------------------ -
......... :.....
THE COMMONWEALTH OF MASSACHUSETTS
- BOARD OF HEALTH
N !.. OF....... >
Appfiration for Dispaoal Workv Cnomitrurtion Pumit
Application is made•for a Permit to: Construct oi•Re air an Individual. Sewage Dis osal
Siystelln
PP Y (••)„ P ( ) g P
1
n o//n�g A�pdttdress
.... ..--- "�r+'�_ __.zi........................ ...... �
. ..__ _________..___-•.---...--- �.(_.__-____-__.______._............__..
Address
W --- 7�/!
Installer Address /1 /
Q Type of Buildi . Size Lot... ______---------------Sq. feet
V DwellingNo. of Bedrooms..---: '" ..___Expansion Attic '( ) Garbage Grinder ( )
aOther—Type
of Building ____________________________ No. of persons............................. Showers ( ) Cafeteria ( )
d Other fixturet5 .Z.d_gallons
............................................................................................. = ".'''m�.�-.....................
Design Flow'______________ er erson er da Total dail flow._.____.._._._:.....__________ allons.
W �• P P P Y Y _-_ g�W Septic Tank Liquid capacit/ .____-_gallons Length................ Width................ Diameter................. Depth................
x Disposal Trench—No_____________________ Width.......... _ ___ Tot hl ength.___ ______ . Total leaching area....................sq. ft.
Seepage Pit No..../:------------- Diameter!-,�__ ___�___ Rep& o f � ___.__. Total leaching area._....._...____...sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed bY.................................=........................................ Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water-________--__-_---_--_--
44 Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water........................
O Description of;Soil:----------------------.--------=--•------�,c'----�� �' ------------------------------------------
� -----
x
w
UNature of Repairs or Alterations—Answer when applicable.____.___:..................:..................................................................
--------------------------••----•••_.....••-•-••••-------_._...:--_••••••••-•-••--••••-•--•-••=----------------------------------------------------------------------------------------------------------
Agreement: .
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system ill
operation until a Certificate of Compliance has.b�ejssd by oArd of heah. xSig � ° `d ./ -- ---sl_�-------- - --- ...
----------
4 'f
�� a Date
Application Approved By------ �'�' �". - '�
r = �.` --------
Dhe_
Application Disapproved for the following reasons:---------_..................._.........._______________________________________________________________________
•-•----•--•---•----•--••---•-...•--•---•-------------------------•--•••---•----•-•-••--------•--•••--•---••--••--•-•••---•--•---.---•------•------••...•-••------- ---------
Date
PermitNo......................................................... Issu*ed........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD QF HEALTH
TntifirFatr d 01.1,11mpti atta
T. S TOrfTI ,�?That t e Individual Sewage Disposal System constructed ( or Repairedby = :. -- ►, I —S-----------------
sit' ;r
ner
�I
---' `_... . � "r4. ..... ---•- Y ._._.......................................................................
has been installed in accordance with the provisions of Artic e X of The State Sanitary Code a described in the
application for Disposal Works Construction Permit No......................__�/ -{.,__. dated-._._..� /_ `✓ '�
THE ISSUANCE OF THIS CERTIFICATE SHALL.NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE �- � ------_....-•-•------==-- Inspector.........G- ' C`-
THE COMMONWEALTH .OF MASSACHUSETTS
,z•...:i,. . BOARD OF HEALTH
.:.....OF.... F -51
._a.--
.............................
EEC.
Permtsston,i reb ranted::__- %"1.._.� _ .� ......... -------------------------
to Co str t r-Repair (J )�n Individual $waged isp sal System
at No.._____k
as shown on the application for Disposal Works Construction Pe i o::_______ ed..__ __�`� ,, -••--•-
Board of Health
DATE--------- ...... .—__ -. .....-•-•-...----
FORM 1255 HOBBS & WARREN. IiNC.. PUBLISHERS ,