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Home My WebLink About0004 ARROWHEAD DRIVE - Health 4, Nrrowhead Drive- Hyannis A= 270-049-001 a I i I i I i 0 0 D TOWN OF BARNSTABLE TION SEWAGE # AGE Ro C, n ASSESSOR'S MAP & LOT STALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY �, LEACHING FACILITY: (type) �Q� (size) NO.OF BEDROOMS BUILDER OR OWNER �t PERMTTDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) '—`� Feet Furnished by `1 �� t. O �J �► �s � _ c� c� . � rr s� I� � � . � � -� �� , _. ��- Commonwealth of Massachusetts lugTitle 5 official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form Inspection results must be submitted on this form. Inspection forms may not be altered In any way. A. General Information Important: When filling out 1. Property Infor ;tlon: forms on the J computer,use C ( t1 t S only the tab key Property Address to move your el-c rL�OcrSxh cursor.do not -4 use the return Owner's Name key. 2-11M�12_ Owner's Address WQ afL h�� N�14 QZIaJ� Clty/Town V State Zlp Code Date of Inspection: �1 3 `QG' f!1° Date 2. Inspector: 1 Na of Ins ctor / Company Name -�----=�0 4 to b `A Company 6q,,,0 n,,.U o- AA 4 2i<,3 Z- Cltyrrown State Zlp Code / Telephone Numbei B. Certification I certify that I have personally inspected the sewage disposal system at this address and-that the r� 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&1 Tide 5(310 CMR 15.000).The system: — r— asses ❑ Conditionally Passes ❑ Fails —❑— Needs Further Evaluation by the Local Approving Authority � `131 --0 (411 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 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. t5insp.doe.doe•03/2008 Title 5 Official tnspecton Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B.-CeMfication (cont.) y "3"8 r Prope Address t'� IY� Oct c4r' stele 2Jp Code Owner's Name Date of Inspection Inspection Summary: Check 'A B,C,D'or E/always complete all of Setition D A) �have noPasses: I ` ffound-any'inforniati6n which tndtcates tliat-any'C)f-Me faiture-'criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are Indicated below. Comments: B) System Conditionatty Passes: ❑ One or more system components-as described in th onditional Pass•section need to be replaced or repaired. The system, upon com.pl -of the replacement-or repair,'as approved by the Board of Health, will pass. Answer yes, no or not determined(Y,.N )in-the-0.for the following statements. if'not determined;' please.explain. The septic tank is metal ver 20 years old'or the septic tank(whether metal or not)is structuraey unsound, ex i its substantial infiltration or exfittrabon or tank failure is imminent. System will pass insp i if the existing tank is,replaced with a complying septic tank as approved by the f ealth. *A metal septic nk will pass inspection if it-is structurally sound, not leaking and if a Certificate of Compliance ndicating that the tank is less than 20 years old is available. ND Explain: t5tnep.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certifi!r"gc( n (cunt.) -i^. Property ddress City/Town State Zip Code At & .- Owner's Name bate of InspecUon B) System Conditionally Passes(cunt.): ❑ 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 s broken, sett) _ r uneven.distribution.box..System will pass inspection if(with approval of Board'af Healt ❑ broken pipe(s)are replaced j ❑ obstruction is remove ❑ distribution is leveled or replaced ND Explain: ❑ 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, 0 obstruction is removed ND.Explain: C) Further Evaluation is Required b e Board of Health: ❑ Conditions exist which require her evaluation by the Board of Health in order to determine if the system-Is failing to prot public health, safety or the environment. 1. System will pass ess Board of Health determines in accordance with 310 CUR 15.3Q3(1.)(bj thatth system.i5 nQtfUnct Qn..itig in'd[1LanrliP[tii li_iGl�:gill.ltrQt4 t Rtibl[F h 1.. safety and the a lronment: ❑ Cess of or privy is within 50 feet of a surface water ❑ C sspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 18 Not for Voluntary Assessments Subsurface Sewage Disposal System. Form. B. Certification (cent.) kk Af�La �- Property Address ar<�N L:> P� 0 ?�oC// City/Towry State ZIp Code Owner's Name Date of Inspection C) Further Evaluation is Requited by the BQarfd.of Health(cQn t,)z 2.. System will fall unless.the Board.of.Health(and.Public.Water Supplier.,.If.any). determines that-the system is functioning-ina manner-that-protects-the.publ' health-, safety and environment: ❑ The system.has.aseptic.tank and soil absorption system.(SAS)an he SAS is within 100 feet of a surface water supply or Inbutaryto a surface wate upply. ❑ The system has.a.septic.tank.and.SAS.and.the.SAS.is hin a.Zone.1 of.a.public water supply: ❑ The system.has a septic.tank and.SAS and,t .SAS.iawithin.50.feet of a private.water supply well. ❑ The system has a septic tank and S and the SAS is less than 100 feet but 50 feet or more from a private water supply elr*. Method used to-determine-di nce: **This system passes if the well 'at analysis; performed at a.DEP certified laboratory, for coliform bacteria indicates absent and the esence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5.ppm, provided.that n . ther failure.criteda.are-triggered. A copy.of the.analysis must be attached to this form. i 3. Other. t5lnsp.doc.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certifi tion (cunt.) taw Prope Address City/Tow state IJpCode Owners Name Date of Inspection D)System Failure Criteria Applicable to All Systems: You must Indicate"Yes"or"No"to each of the following for all Inspections: Yes No El ti,4 Backup of sewage into facility or system component due to overloaded or �! clogged SAS or cesspool ❑ 14 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 _ ❑ Uquid depth in cesspool is less than 6"below invert or available volume is less than%day flow ❑ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ E� 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. ❑ E� 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 certitled laboratory,for fecal collform 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. Yes No ❑ The system falls. 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. t5lnsp.doc.doc•0312006 Title 5 Official Inspection Form:subsurface sewage Disposal system Page 5 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form B. Certification (cons.) Lt k C Props Address 5 rii l9- L / CttyfToyrQ state Zip Code lv 3-ct Owners Name Date of Inspection i E) Large Systems: To be considered a large system the system mu rve 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 eac the following, in addition to the questions in Section D. YES NO ❑ ❑ the system Is withi 0 feet of a surface drinking water supply ❑ ❑ the system' within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the sy m is located in a nitrogen sensitive area(Interim Wellhead Protection Ar —IWPA)or a mapped Zone II of a public water supply well If you have answer '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 failed.The owner or operator of any large system consi ed a significant threat under Section E or failed under Section D shall upgrade the system in rdance with 310 CMR 15.304. The system owner should contact the appropriate regional ce of the Department. t5lnsp.doc.doc•03/2008 This 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System 1pfornpation LA e-d -br Props Address n 1 r%L CttyfTowv State 23p Code < < rQ- t3�� Owner's Name Date of Inspection Residential Flow Conditions: Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: z9 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? �A Yes ❑ No Seasonal use? ❑ Yes No Water meter readings, if available(last 2 years usage(gpd)): 7 Sump pump? ❑ Yes ( No Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): c per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): I Grease trap present? I ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to th itle 5 system? ❑ Yes ❑ No Water meter readings, if availabl . Last date of occupancy/use: Date Other(describe): t5insp.doc.doc•03/2006 Title S Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System lqformation (cont.) Pro rty Address City/T n State !- ZlpCode • c K-C� f0�t3 � Owner's Name Date of Inspection General Information ` Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes.lam No If yes, volume pumped: /0 gallons How was quantity pumped determined? --D4 12ecv"- Reason for pumping: i Type of System: zEr 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) El maintenance technology. Attach a copy of the current operation and maintenance contract(to be obtained 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 information: Were sewage odors detected when arriving at the site? ❑ Yes No t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. Syste Information (cunt.) ! Property dress cl c. WLo�- a'Z�it City/Town State Zlp Code . V. Vc�,(5N� Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑cast iron V0 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet I 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 ❑ Yes ❑ No certificate ------------------------------------------------------------------------------------------------------ Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 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 _I- How were dimensions determined? t5insp.doc.doc•0312006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 10 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. Syste Information (cunt.) Property Address 'l.ri r1 L Clty/To State Zip Code �, &-f3-4: 4 Owner's Name Date of Inspection Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(loc a on site plan): Depth below ade: feet Material construction: ❑c crete ❑ metal ❑fiberglass ❑polyethylene ❑other(explain): i Dimensions.. Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped.at-time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete etal ❑fiberglass ❑polyethylene ❑other(explain): t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 11 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) Property Address Clty/To State .Zip Code Owner's Name Date of Inspection Tight or Holding Tank(cunt.) 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.): <a, 'Attach copy of current pumping contract(required). Is copy aft d? ❑ Yes ❑ No Distribution Box(if present must be opened) a on site plan): Depth of liquid level above outlet i Comments(note if box is I and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage i or out of box, etc.): Pump Chamber(locate on site pla Pumps in working order: ❑ Yes ❑ No j Alarms in working orde . ❑ Yes ❑ No t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form UVNot for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) 4 ,lr- Property Address Ea...,..s u - b2rov City/Town V State Zip Code s to" 3 0 Ce Owner's Name Date of Inspection 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: i I Type: leaching pits number. ❑ leaching chambers number. ❑ leaching galleries number. ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number. ❑ innovativetalternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): AA Xwws Nome t5insp.doc.doc•0312006 Title 5 Official Inspection Form;Subsurface$ewagq plsposal$ystgm Page 13 of 16 Commonwealth of Massachusetts .� Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System=LOCI tion (cunt.) E r-- Propertydress /V Cfty[TownV State Zip Code Owners tame Date of Inspection 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 i Materials of construction Indication of ground r inflow ❑ Yes ❑ No Comments(not ondition 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 soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 7 t5insp.doc.doc•03/2006 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 14 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. Systemsn Information (cunt.) - Pra pe Address citylto State Zlp Code A ro - Owner's Name Date of Inspection 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. RT o2� . o -...__.._,....... rvim;ouosunace sewage Disposal System Page 15 of IS l . Commonwealth of Massachusetts � Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form D. System Information (cont.) Property r ss City/TPwn State Zip Code .Jer"t Co -13-�0 6 Owner's Na Date of Inspection Site Exam: Slope Surface water Check cellar Shallow wells Estimated depth to ground water: Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑� Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: i I ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: �1 1C�T �L?r ��5 t✓� !2 fig t5insp.doc.doc•03/200e Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 .... COMMONWEALTH OF MASSAUSETTS CH EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS John Graci DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119 TeaTicket,Ma. (508)564-6813 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION F Property Address: .629 RT. 28 HYANNIS ° Name of Owner DENNIS MAHONEY Address of Owner: 496 OLD JAIL LANE BARNSTABLE MA.02630 s IS'� e Date of Inspection: 9/2199 ro j' <Q Name of Inspector:(Please Print)JOHN GRACIo 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) ��9 j99 a� �o�srq 9 Company Name: nla Mailing Address: nla \ Telephone Number: n/a 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 sewage disposal systems.The system: X Passes The inpection is based on criteria defined in Title V Conditionally Passes code 310 CMR 15.303.My findings are of how the system is Needs Further Evaluation By the Local Approving Authority performing at the time of the Inspection.My Inspection does Fails not Imply any warranty or guarantee of the longgevity of the septic system and any of its components useful life. Inspector's Signature: Date:9/1199 The System Inspector shall bmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(30)days of completing this inspection.I 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.Environ mental Protection.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ' NOTES AND COMMENTS THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING SYSTEM NOW AND THEN MAINTAIN EVERY YEAR.RECOMMEND MOVING THE TELEPHONE LINE THAT IS OVER COVER OF PIT. revised 9/2/98 Page 1 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 629 RT.28 HYANNIS Owner: DENNIS MAHONEY Date of Inspection:912199 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated are indicated below. COMMENTS: System passes Title V inspection B. SYSTEM CONDITIONALLY PASSES: I nLa 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. Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not. nLa 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. nLa 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 nLa 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 revised 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A . CERTIFICATION(continued) Property Address: 629 RT.28 HYANNIS Owner: DENNIS MAHONEY Date of Inspection:9/2/99 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. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT 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 Wit-(approximation not valid). 3) OTHER Wit t revised 9/2/98 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 629 RT.28 HYANNIS Owner: DENNIS MAHONEY Date of Inspection:9/2199 D. SYSTEM FAILS: You must indicate either"Yes"or"No"to each of the following: I 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 No X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow, X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Wa. X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone I of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well, X 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 ompounds, ammonia nitrogen and nitrate nitrogen. X The liquid level in the SAS is over the invert pipe,Is in Hydraulic Failure. E. LARGE SYSTEM FAILS: You must 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 X the system is within 400 feet of a surface drinking water supply X the system is within 200 feet of a tributary to a surface drinking water supply X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 629 RT.28 HYANNIS Owner: DENNIS MAHONEY Date of Inspection:912/99 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: Yes No X Pumping information was provided by the owner,occupant,or Board of Health. X None of the system components have been pumped for at least two weeks and-the system has been receiving normal flow rates i during that period.Large volumes of water have not been introduced into the system recently or as part of this inspection. X As built plans have been obtained and examined.Note if they are not available with N/A, X The facility or dwelling was inspected for signs of sewage back-up. X The system does not receive non-sanitary or industrial waste flow. X The site was inspected for signs of breakout, X All system components,excluding the Soil Absorption System,have been located on the site. X 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: X Existing information,For example,Plan at B4O,H, X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable) (1 5.302(3)(b)] X The facility owner(and occupants,if different from owner)were provided with information on the proper-maintenance of SubSurface Disposal Systems. revised 9/2/98 Page 5 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 629 RT.28 HYANNIS Owner: DENNIS MAHONEY Date of Inspection:9/2199 FLOW CONDITIONS RESIDENTIAL: Design flow:-=g.p.d./bedroom Number of bedrooms(design): 2 Number of bedrooms(actual):2 Total DESIGN flow: = Number of current residents:2 Garbage grinder(yes or no):NQ Laundry(separate system)(yes or no): NO If yes,separate inspection required Laundry system inspected(yes or no):M Seasonal use(yes or no):JLQ Water meter readings,if available(last two year's usage(gpd): nfa Sump Pump(yes or no): NQ Last date of occupancy: n(a COM M ERCIALIINDUSTRIAL Type of establishment: Wit Design flow: Wit gpd(Based on 15.203) Basis of design flow: n/a Grease trap present:(yes or no):.J1LQ Industrial Waste Holding Tank present:(yes or no): NQ Non-sanitary waste discharged to the Title 5 system:(yes or no):MG Water meter readings.if available:n/a Last date of occupancy: n& OTHER: (Describe) n/a Last date of occupancy:.n& GENERAL INFORMATION PUMPING RECORDS and source of information: nla System pumped as part of inspection:(yes or no):MQ If yes,volume pumped nla_ gallons Reason for pumping: n& TYPE OF SYSTEM X 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: n/a APPROXIMATE AGE of all components,date installed(if known)and source of information: THE SYSTEM IS 12 YEARS OLD. Sewage odors detected when arriving at the site:(yes or no): flLQ revised 9/2198 Page 6 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 629 RT.28 HYANNIS Owner: DENNIS MAHONEY Date of Inspection:912/99 BUILDING SEWER: (Locate on site plan) Depth below grade: 1'C Material of construction:_ cast iron X 40 PVC _ other(explain) Distance from private water supply well or suction line: TOWN Diameter: nLa Comments: (condition of joints,venting,evidence of leakage,etc.) nta SEPTIC TANK: X (locate on site plan) Depth below grade: i Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain) n& If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NQ nLa Dimensions: L 8'6"H 5'7"W 4'10" Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: L Scum thickness: Distance from top of scum to top of outlet tee or baffle: 6" Distance from bottom of scum to bottom of outlet tee or baffle: ],i How dimensions were determined: MEASURED Comments: (recommendation for pumping,condition of inlet.and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage, etc.) SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND RECOMMEND PUMPING NOW AND THEN MAINTAINED EVERY YEAR GREASE TRAP: (locate on site plan) Depth below grade: Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain) nLa Dimensions: nLa Scum thickness: nLa Distance from top of scum to top of outlet tee or baffle:-n& Distance from bottom of scum to bottom of outlet tee or baffle Wa Date of last pumping: Wa Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,. etc.) nla revised 9/2/98 Page 7 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 629 RT.28 HYANNIS Owner: DENNIS MAHONEY Date of Inspection:912199 TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection) (locate on site plan) Depth below grade: n/a Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain) n/a Dimensions: nLa Capacity: nLa gallons Design flow: nta gallons/day Alarm present: MQ Alarm level:jiLa_ Alarm in working order:Yes—No—: NQ Date of previous pumping: n& Comments: (condition of inlet tee,condition of alarm and float switches,etc.) Wa DISTRIBUTION BOX: _ (locate on site plan) Depth of liquid level above outlet invert:Wa Comments: (note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP CHAMBER: NQ (locate on site plan) Pumps in working order:(Yes or No): NO Alarms in working order(Yes or No): NQ Comments: (note condition of pump chamber,condition of pumps and appurtenances.etc.) nLa revised 9/2/98 Page 8 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 629 RT.28 HYANNIS Owner: DENNIS MAHONEY Date of Inspection:9l2/99 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods) If not located,explain: Wa Type: leaching pits,number: 1000 GALLON LEACH PIT leaching chambers,number: _n[a leaching galleries,number: j3& leaching trenches,number,length: n& leaching fields,number,dimensions: n& overflow cesspool,number: n& Alternative system: n[a Name of Technology: _n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.) THE LEACH PIT IS STRUCTURALL SOUND AND FUNTIONING PROPERLY TH PIT HAD 2'OF LEACHING LEFT AT THE TIME OF THE INSPECTION. CESSPOOLS: _ (locate on site plan) Number and configuration: nla Depth-top of liquid to inlet invert: n& Depth of solids layer: n(a Depth of scum layer. n& Dimensions of cesspool: nla Materials of construction: nfa Indication of groundwater: nla inflow(cesspool must be pumped as part of inspection)n(a Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) PRIVY: _ (locate on site plan) Materials of construction:nfa Dimensions:n& Depth of solids: n& Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.) Wa I revised 9/2/98 Page 9 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 629 RT.28 HYANNIS Owner: DENNIS MAHONEY Date of Inspection:9/2/99 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) n/a A 1J I A tg 6 Pho�c C I rn e A� (l L 49 2q AC � 23 a� 3° revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 629 RT.28 HYANNIS Owner: DENNIS MAHONEY Date of Inspection:9l2/99 NRCS Report name: n& Soil Type: n& Typical depth to groundwater: n& USGS Date website visited: n(a Observation Wells checked: NO Groundwater depth:Shallow _ Moderate _ Deep _ SITE EXAM _ Slope _ Surface water _ Check Cellar Shallow wells Estimated Depth to Groundwater 12 Feet I i Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained from Design Plans on record _ Observed Site(Abutting property,observation hole,basement sump etc.) _ Determined from local conditions _ Checked with local Board of health _ Checked FEMA Maps Checked pumping records _ Checked local excavators,installers X Used USGS Data Describe how you established the High Groundwater Elevation.(Must be completed) USGS MAPS AND CHARTS revised 9/2/98 Page 11 of 11 3 1 � / 966T 01 XVW SUBSURFACE SEWAGE ,DISPOSAL SYSTEM •INSPECT] ONCM130311 Address of prop rty lam. i" � Owner' s .name Date of Inspection 5--�-`�" 5 P CArll - ly7 . � PART A CHECRLI Check. if the following have been done: Pumping information was requested of the owner, •occup t; . and Board of Health. V**" 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_ .NjA. r V The facility or. dwelling was inspected for -signs of- sewage back=up. The site was inspected for signs of- breakout. { All system components, excluding the SAS, 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. ofI sludge, depth• of scum. /The size and location of the SAS on the site has- been determined based on existing information or approximated by non=intrusive methods. The facility owner • (and occupants, if different from owner) were provided 'with information' on the proper maintenance of SSDS. 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents Alo garbage grinder, yes or no, S laundry connected to system, yes or no N'v seasonal use, yes or. no If nonresidential, calculated flow: Water meter readings, if, available: Last date of occupancy GENERAL INFORMATION Pumping records and source of information: - System pumped as part of inspection, yes or no if yes, volume pumped itic Reason for pumping: Typ 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) Other (explain) Approximate age of all components. Date installed, if known. Source of information: Sewage odors detected when arrivingat the site es or no- • y v 9 b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK:_z (locate on site plan) depth below grade:_ ' material of construction: _-Z—Concrete metal FRP other(explain) dimensions: sludge depth ,_ distance from top of sludge to bottom of outlet tee or baffle _ 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 Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, recommendations for repairs, etc. ) L; 1 DISTRIBUTION BOX: (locate on site plan) /i depth of liquid level above outlet invert Comments: (note if level and -distribution is equal, evidence of solids carryover, evidence of leakage into or out of box recommendation for repairs, etc. ) wG\.4✓ UL'e( in Sip � '�unK yAu �� 4��;.h �� ,.�a� '� t,E �d, ��L tom} �r►�cr4' PUMP CHAMBER (locate on site plan) pumps - in working -order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, . recommendations for maintenance or repairs,etc. ) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE - =SPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100 ' ASK OF , &or DEPTH TO GROUNDWATER t depth to groundwater method of determination or approximation.: 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS) : (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type. leaching pits and number j leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool , number Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs, etc. ) CESSPOOLS (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 (cesspool must be pumped as part of inspection) i Comments : (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) PRIVY : (locate on site plan) materials of construction A//a' dimensions depth of solids Comments: (note condition of soil , signs of hydraulic failure, level of ponding, condition of vegetation, recommendations for maintenance or repairs,etc. ) 12 i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, - or not determined (Y, N, or ND) . Describe basis of determination in all instances. If "not determined" , explain why not) Backup of sewage into facility? kDischarge or ponding of effluent to the surface of the ground or surface waters? Static liquid level in the distribution box above outlet invert? y0 C.�Bpcj AR Liquid depth in cesspool <6" below invert or, available volume< 1/2 day flow? N Required pumping 4 times or more in the last year? number of times pumped Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? Is any portion of the SAS, cesspool or privy: below the high groundwater elevation? within 50 feet of a surface water? within 100 feet of a surface water supply or tributary to *a surface water supply? 'within a Zone I of a public well? within 50 'feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not the SAS) ? within 50 feet of a private water supply well? 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 analysi� . for coliform bacteria, ' volatile organic compounds, ammonia nitrogen and nitrate n,itrogen'. • 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector � � Company Name ^ Company Address &cl Certification Statement I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in .the proper function and manitenance of on-site sewage disposal systems. Check ne: have not found any information which indicates that the system .fails to adequately protect public health or the environment as defined in 310 CMR 15. 303 . Any' failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15. 303 . The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector' s Signature / Date Original to system owner Copies to: Buyer ( if applicable) Approving authority rp-llll�, a 9/-y s-� a L-b . A T ION SEWAGE PERMIT NO. ti :r /A INS LLER'S NAME A ADDRE S �I U D E R OR OWN ER ODATE PERMIT ISSUED DAT- E COMPLIANCE ISSUED � �� O r - ems- Pa No ......9�� 29� 1 Fizic ................. THE COKWONWEALTH OF MASSACHUSETTS BOARD 0,F HEALTH --------------OF............ ..... Appliration for Bissau al Works Tonstrurtion VarAft Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Sy t at , ....A40P e .................. .......... . .... .. .... .......ZeP....... ......................... ocation-Ad ress ... ... ............. .. n . .. ..... ...... .... . . . ... . Address dd.ress....... or ...... ................. Installer Address T e of Building Size Lot..4&ia._'1._j..I.§q. feet Dwelling—No. of Bedrooms........2...............................Expansion Attic Garbage Grinder Other—Type of Building .... ... No. of persons.......'7'_1................ Showers Cafeteria Otherfixtures ...... .......................................................................................................................... Design Flow........ 1.4)..........................gallons per person day. Total daily flow........J..3_0..................gall2ns. Septic Tank—Liquid'capacity/~-. .gallons Length...'el�r------ Width.....45.wo..... Diameter................ Depth....?......__. Disposal Trench—No. .................... Width.............__.._.. Total Length......_.-_,,e....... Total leaching area....... ft. Seepage Pit No......./........... Diameter.......Z-V..... Depth below inlet (-.a.......... Total leaching area....ZtC--fiPq. f t. Z Other*Distribution box Dosing e of -7 Percolation Test Results Performed by....._ � --1i -------- ............. Date.......4.=13....... Test Pit,No. 1....J—V...minutes per inch Depth of Test Pit-___'*.............. Depth to ground water____................___. LX4 Test-Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.........._............. 04 .......... ..... .......................................... ............ ..............11 ............ '0 .1e � - 0....... ................ 0 Description of Soil------. ---- --------- -- ------ ---------- ------ ---- ---*-------------- ..........................................:�............................ V-'Ov 000 - U .................... --- ...............I................................................................. W ........................................................................................................................................................................................................ M U Nature of Repairs or Alterations—Answer when applicable............................................................................................... ................................................................................0....................................................................................................................... Agreem Minder_. - signed agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the ro- s' is f TITI;j,' -5 of the, tate Sanitary Code—The d ' ned further agrees not to place the system in e under n 0 era un a fi f pliance has issu by the boar f a Signed............ .............. ................ . .... . Y bate- ..�2 �� .... ................................... ........................................ pp cati n A ved By............. A pli tion Disapproved for the following reasons:............7�1 Date ----------------------------------------------- --------- -------------------------------------------------------------------*---------------------------------------------------------------* ---------Date-------------- --------Date*------------- PermitNo......................................................... Issued....................................................... Date ---------- ------------ No.......----...._....... r Fps........................... . THE CO"%IONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF...........................-................... ApplirFation for Disposal Works Tonstrurtion umit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ................___....-...................................................................... •......---.......-------.....----......---.......--------.......-------.....------........-------- Location-Address or Lot No. ......................^.......................................................................... ••---•----•......-----...:.-•--•-•----.........-----•---..._..........----.............-.......--- aOwner Address Installer Address Type of Building Size Lot............................Sq. feet Dwelling—No. of Bedrooms...........................................Expansion'Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) d Other fixtures .............. :---------------------------------------.-----•------......-----•------------•------------••-------------•-••-•----......_•------------- W . Design Flow..........................................::gallons per person per day. Total daily flow............................................gallons. 04 W Septic Tank—Liquid'capacity............gallons Length................ Width................ Diameter----............ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. 3 Seepage Pit No..................... Diameter.............. Depth below inlet_.........._.._.__.. Total leaching area..................sq. ft. Z Other Distribution box ( ) . Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.................... 04 Test Pit No. 2................minutes per inch Depth of Test Pit:-.-- ... Depth to ground water....................---. ....-•...............•-•------•---•-••-•---........--•-•-•--••------...---------....•--_-- •----......................................................... O _ I.. Description of Soil........................................................................................................................................................................ V ---••-----•---------------•---••------•-••---•-•--••-----------•--••------------......-_.....------••----••---------•---•-•••-----•--•-•----...•-------•-•---------------•-•------.....----._..._-•-••- ------------------------•---------------------------.------------.....-••------••----•-----------•--•----•---•-;-----------------•---- ------------- U Nature of Repairs or Alterations_—Answer when applicable............................................................................................... ='==------•-------------•-••-------••-•-------•....----------••-------•---------•--------•-------•-•-------••---•----•--------------....-----.....-••-- Agree. e lndersigned agrees to install the aforedescribed Individual Sewage,—Disposal—System in accordance with the ro s' us f TIT' , . of the tate Sanitary Code—The undersigned further agrees not to place the system in o era u a fi .t`� .of pliance has been issued by the board of health. �:. Signed........... -•----------------•---•------...------•--------•-------- Date PPcat n ved y-------------------------------------------------------------------------------------------------- ........................................ Date A pli tion Disapproved for the following reasons:--••----•...............•-••-----•-•---••--•--•-•-••------------•------ ...................................... i --- ........•-•--------------------------------------•-•--------•••-•------•-•----.._.....-----....--•------------•......----•-----•--•••------------•---•---•------------•--•...........------_..... Date PermitNo.................................•---•-•--------•------. Issued_....................................................... Date +"+ %THE;COMMONWEALTH OF MASSACHUSETTS t, BOARD OF HEALTH Tutifirab of TuntpliFanre THI_Y IS TO CERTI Y, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) `'' d 1 ' /I Installer at.. AJ-• / ,' G :�e......Zc _...1 _ '-•--•-------•-•-----•---•---•--------•---•---------•-•----------•--•------------ has been installed in accordance with the provisions of TITLE of The State Sanitary Co e/as described in the application for Disposal Works Construction Permit No.- ------- ti.'a> .......... dated---- ,�f L% ._. ....�,_ .COG� THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM W FU CTION SATISFACTORY. ` r DATE y _..•.................................................... Inspector...-='--.. .---J-.--- THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEALTH Nol.ij'! o ......................... FEE..... ................. it s nrkii Tnnofra inn rrmit Permission is hereby granted !p F2-4----•--4/A.4.-..--------------------------------------------------•-....--•---...-•---................ to Construct ( ) or\Re air ( ) awn I,Qdividual Sewage Disposal System at No-----/- A .'G�c..2c,1� �7&_0.4. -ep.f Street t ,r� r as shown on the application' for Disposal Works Construction Permit No................ Dated---- --------------------•--•-•---•--...=-.............'-------------------•------•------••--•--••-- Board of Health DATE----------- . ..........................•----••----- r ''FORM 1255 A.-"M. SULKIN, INC., BOSTON - + ,s . J'I �11 ` -.� a. .. ` jar N - :1 SAP �. •�. � ;",x.:k s..., col •�( '' , o4-1 Q. tj VIA I1 ' •/ k's i .r'' s � 0 c Ys Ll or ZV/✓E R=8 .f ' ' k o jarr t� ORSE /U p u w i ,, e, rJ o.10951�Q ti S• 3. /o,0 1.✓/J�Tr>. tairG/STEP LEGEND = r � d ° .PLOAN EXISTING 9POT ELEVATION PL • Ox0 Y` ' CERTIFIED T .---� t r t?a i EXISTING CONTOUR ---,p — — �H OF M,�SS yam;` ut FINISHED SPOT ELEVATION — FioaERr' . t. ►. < F; ' FINISHED CONTOUR 0 -5RRuC 'ELDRE IN i APPROVED I-BOARD OF HEALTH, , DATE AGENT LDREDBE EWINEER/NQ CQ wo jaA/Z.NSTlq race ;:i;.;CERTIFY THAT.'TNL .•PINVP6ft , EOISTERE REGISTERED °T JOb•N0.:944 WiLDIN0 - SHOWN _ ON THIS PL-Aff {� - CIVIL LAND CONFORMS ;TO •'TME_-:ZONINA '-LAWN " ." ENGINEER URVEYOR OR�SY' •r '• 'OF:, BARNSTABLE; MASS' 4`r 712 MAIN STREET CHBY=2 H YAW N I S, MASB gHEET` :0 s .� REG.. LAND ., SURVEYOR r,e++ /VOTE : /F E/TNER THE SEPTIC TAN/C OR 20 FT.. M//V- LEAcAll a PIT .4RE MORE T/dAJV I2-48ELOI'V /D Pr- M/N• ..riRAOE,AI �Q'O/ METER COiyC.r.ETL� COYE'� SWAL L &,F ,SQDI/6.V T TO GRA 0E.�f,V EX77M A GONC/t�E 4�PVG' P/PE t,►ERVY CAST/RO/Y COVET! S/YALL D.E USEO M/N. P/TCN iE L . 103 p COYE/TS PLC f'T /F/I1/ OR/VEN/A Y A : dcE CO✓ER CLEAN SANO eACX F/L.L - - �• LQl//O LEVEL :..• -: ,. 41 IRON P/P r O(J C •• ,- � - -; b OF ' -' NOM P/TCN GAL. I • • • • • • • • e e WASHED 57?7NE 0 14-Pffig.J7 SEPTIC TANK D/ST. • + , , . . . • • BOX o . I B . . • • • • . . /s X o PRECAST SEfA4GE .. ��? c•�/'4 C i-r y 4 9 U �rE}L/pro�/ / ►. • • • • • • • • • • o P/7 OR EQl!/Y .47 INVERT AT OLIILDIJV6 9 9,O FT. G JT D/AM. _ INLET SW'r/C' T.4NK 9 8• FT. F7 O/i4J�'1. C�SFE T�t/LA'TJow� OUTLET SEPT/C TANK. 17, - _7_7VLEr DISTRIAOT/ON BOX 9 G-$A7. OF". GROUND INTER TAQLE OVTYETD/SlR/sUTiON BQX 9 G A 07. I/VLET L.EACNIwG of r gs.J_Fr SEN/AGE �/SPO�S.4L SYSTEM 7AWLATI40N LEACHING PIT v,JyEJvs/oa Il_�` -SCALE : �4 DESI6/V CR/TERM OJJ AW-1/0AI 40 FT• IVtlAlOER OF BEGROOAIS D/MENS/OJV C iT. K GARaAGEO/SPO.SaL(/IV/T WE" - SOIL LOG TOTAL EST/IrY�7'EG FLO/�V 3 3� G.4t./O�4y SOI L TEST A�'/ So/L 7WST02 SD/L TE1T E[EY. - r'Y. GA TE OF SO/L TEST i NUMBER OF LE�rCNI� P/rs 0O—L_ f� ,�`A-L S/Olr LEACHING PER P/T 5a wr i RESULTS ITV/7-NE=R,0 dY C L s s OOTTOM Lz4.CN/NG PER P/T L 13 SO. FT o� L�A-M � PERCOLAT/ON RArAF At! MJHSI/NGN TOTAL LP_,4CN/NG AREA ESQ. FT ° Sd,- PrRCOLAT/aN RATE*Z Z MJNVINCH RESERi�EL64CNlN6AREA 7- SQ. FT. a 9 S,S- l— of yo "--A OF , tss \ �ZH M�Ss MIDI VAJ a c�7 E ROBERT yG,' �o� ALB BRUCE ELDRE a se y s ELOREVCW FAArs/NEAR1hW CCU/NC. No.10951 O -o Q I(,;, <v� 7t2 MAIN sF/ NYANN/9, MASS. F ig E CQ` qo FGfST Np 51f� �FSOUNAI-ENS'\ C3 NO 6/TOCIND y1�i4TER �/{/COUNT1�REo CL/ENT M o h nls 93 G/tO t1Na LVsl TER AT ErLEY. .l Dd A/n 84 0 z'`f- S✓<lE�T Z-Of