HomeMy WebLinkAbout0072 ARROWHEAD DRIVE - Health 72 Arrowhead-Drive
Hyannis
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No. Fee 4v
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTAB.LE, MASSACHUSETTS Yes
.Zlpph.ration for IDiopozat 6p5tim ConOtruction Vermit
Application for a Permit to Construct( ) Repair Co" Upgrade( ) Abandon( ) ❑.Complete System Individual Components
Location Address or Lot No. 11 q tto ,JbeAJ lj(',vE Owner's Name,Address;and Tel.No. 1 OblJ 9(, .
hi.ial.nni s 1S33
Assessor's Map/Parcel 'Z.� ,Z CeiwT�i ii I le
Installer's Name,Address,and Tel.No.lf4pew iC�sl �vQr�3 Designer's Name,Address and Tel.No.
(r,e wi r`l .-, t Z
Type of Building:
Dwelling No.of Bedrooms 2 Lot Size �,Sbo sq.ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) 3 3a gpd Design flow provided gpd
Plan Date Number of sheets Revision Date
i
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) 1kp�4<a "b—3 p�[
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
Signe Date
Application Approved by Date
Application Disapproved by. Date
for the following reasons
Permit No. �®�� Date Issued
/.� +'rit�t.'YyC{�µwy'1 �tStoSx►Tai/"rr'a •3+�`'"'C*j�,hi+"i`P�.�•>2Y""�' ibvl�vl'�'-�..�rf7i�r '„- i':4,.,�¢--�i..e•r.:.ii�+r.v..I�, •- •a-.I:;,:.r,�.r:....-_:ram— '��;
Fee
THE COMMONWEALTH MASSACHUSETTS Entered in computer:
PUBLIC.HEALTH DIVISION .TOWN Ofr"BARNSTAB.LE, MASSACHUSETTS Yes
pplication for �Diopoal *pgtiem Conk tructio nC Permit t,,
Application for a Permit to Construct O Repair Upgrade O Abandon,( j.!❑.Complete System Individual Components
Location Address or Lot No. 12 Adra,3 e.,AJ V';vt- Owner's Name,Address;and Tel.No. TO .6 .
la.l7a nni S 1$33 vuF.4/hater
Assessor's Map/Parcel -III Z e1u,tax
Installer's"Name,Address,and Tel.No.CnQt"'.!u E-� J fj ii K Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size d a, to0� sq. ft. Garbage Grinder ( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
---
Design Flow(min.required) 330 gpd Design flow provided i' gpd
Plan Date Number of sheets evision Date. 'l
_/Title
Size of Septic Tank \ Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)t
Date last inspected:
r Agreement: `
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewagesposal system'inl
' accordance with the provisions of Title 5 of the Environmental Code and not to place the.system in operation until a Certificate ofk
` Compliance has been issued by this Board of Health.
Signed Date
Application Approved by 7 Dates /
Application Disapproved b i Date
for the following reasons 3
Permit No. or)op,-(q Date Issued V
THE COMMONWEALTH OF MASSACHUSETTS
o:- X 0"I y BARNSTABLE, MASSACHUSETTS
t / Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (V Upgraded ( )
Abandoned( )by L lu w)t r1La L7 kl AI:')-e-,5 W..
at Z 14ft6 o,,A L 1R -A bc 4± has been constructed in accordance /
with the provisions of Title 5 and the for Disposal System Construction Permit-No. o (tk— t�t� dated LIZ.
Installer o i /r f, Designer 77
#bedrooms Approved design flow/ gpd
�.
The issuance of this permit shall not be c. trued s ntee that the system will fia fio•.a desig ned.
7
Date Inspector ,
^� /
No. d GV ' % Fee
1 THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS
wigtlont *p5tem Con5trUction Permit
Permission is hereby granted to Construct ( ) Repair' (�) Upgrade ( ) Abandon ( )
System located at '2 A(tow d ha' i f4 Ain am ; S
and as described in the above Application for Disposal System Construction Permit-The applicant recognizes his/her duty j
to comply with Title 5 and the following'local provisions or special conditions.
Provided: Construction must b completed within three years of the date of this e
Date L t 'Approved by /` .r
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Town of Barnstable Barnstable
OF SHE tp� .
h�PN, A&Ammica C ft
Regulatory Services Department
'IARNSTAUI.E. _
`4+9MA 9- Public Health Division 6 g q. �0 .;t W
PrFD MAt A 200 Main Street, Hyannis MA 02601 20057
Office: 508-862-4644 Thomas F.Geiler,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
February 8, 2008
Today Real Estate
1533 Falmouth Road
Centerville, MA 02632
ORDER TO COMPLY WITH STATE`ENVIRONMENTAL CODE, TITLE 5
The septic system located at 72 Arrowhead Drive, Hyannis MA was inspected on
February 2, 2008, by Robert A. Drake, certified Title V Septic Inspector for the State
of Massachusetts.
The inspection of the septic system showed that the system CONDITIONALLY
PASSES under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following:
Distribution box is corroded and cover is cracked.
You are ordered to replace the distribution box within Two (2) years of the date you
receive this notification.
Failure to repair/replace the septic system within the deadline-period will result in'future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
Th s c ean, R.S., CHO
Agent of the.Board of Health
Q:\SEPTIC\Letters Septic Inspection Failures\72 Arrowhead Drive.doc
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated
6/15/2000. Inspection forms may not be altered in any way.
A. Certification
Important:
When filling out 1. Property Information:
forms to the
.computer,use 72 Arrowhead Drive 1 V I o 1
only the tab key Property Address
to move your Today Real Estate
cursor-do not
use the return Owner's Name
key. 1533 Falmouth Road
Owner's Address
Centerville MA 02632
Cityfrown State Zip Code
ICI Date of Inspection: 02/02/08
Date
2. Inspector:
MR. ROBERT A. DRAKE
Name of Inspector
KCJ ENGINEERING
Company Name
66 GREENVILLE DRIVE `t
Company Address 1 ;
FORESTDALE MA 02644 r
Cftyfrown State Zip Code
508-477-5048
Telephone Number
Certification Statement: -
I certify that I have personally inspected the sewage disposal system at this address an that the
information reported below is true, accurate and complete as of the time of the inspectio . The inspection
was performed based on my training and experience in the proper function and mainten nce of on site
sewage disposal systems. I am a DEP approved system inspector pursuant t tion 15.340 of
Title 5(310 CMR 15.000).The system: tOF
H Mgss
El Passes ® Conditionally Passes F ils�
p hGaD TA.
DRAKE
❑ N s Further Evaluation by the Local Approving Authority No.ai�sa2
1
Inspector's Signature Date
SSiO;MM-
The system inspector shall submit a copy of this inspection report to the Ap roving 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.
72 Arrowhead Drive-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection 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
A. Certification (cont.)
72 Arrowhead Drive
Property Address
Hyannis MA 02601
Cityfrown State Zip Code
Today Real Estate 02/02/08
Owner's Name Date of Inspection
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
® One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Answer yes, no or not determined (Y, N, ND)in the❑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.
ND Explain:
D-Box is severley corroded and cover is cracked, needs to be replaced.
72 Arrowhead Drive-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 2of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cont.)
72 Arrowhead Drive
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/02/08
Owner's Name Date of Inspection
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
❑ obstruction is removed
❑ distribution box 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
❑ obstruction is removed
ND Explain:
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,
i
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
72 Arrowhead Drive-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 3 of 16
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
A. Certification (cunt.)
72 Arrowhead Drive
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/02/08
Owner's Name Date of Inspection
C) Further Evaluation is Required by the Board of Health (cunt.):
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
i
❑ 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 i
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.
3. Other:
72 Arrowhead Drive-T51NSP1.DOC.doc•11/2004 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
A. Certification (cont.)
72 Arrowhead Drive
Property Address
Hyannis MA 02601
City/Town State ZipCode
Today Real Estate 02/02/08
Owner's 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
❑ ® 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 Y2 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 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 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.]
Yes No
❑ ® 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.
72 Arrowhead Drive-T51NSP1.DOC.doc•11/2004 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
N
A. Certification (cont.)
72 Arrowhead Drive
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/02/08
Owner's Name Date of Inspection
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.
72 Arrowhead Drive-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 6of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
B. Checklist
Arrowhead Drive
Property Address
Hyannis MA 02601
City/Town State Zip Code
Today Real Estate 02/02/08
Owner's Name Date of Inspection
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
YES NO
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil_Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]
72 Arrowhead Drive-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System•.
Page 7 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_— Not for Voluntary Assessments
r` Subsurface Sewage Disposal System Form
C. System Information
72 Arrowhead Drive
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/02/08
Owner's Name Date of Inspection
Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for'example: 110 gpd x#of bedrooms): 220
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
3
Water meter readings, if available(last 2 years usage(gpd)): L°O( ' t°,G p° 224 gpd
3
Sump pump? lolcl Zao1 : 8,y°0rV ❑ Yes ® No
Last date of occupancy: DDate 10/07
Commercial/Industrial Flow Conditions-
Type of Establishment: N/A
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?' r ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
72 Arrowhead DriveJ51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 8 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
72 Arrowhead Drive
Property Address
Hyannis MA 02601
Cfty/rown State Zip Code
Today Real Estate 02/02/08
Owner's Name Date of Inspection
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection?, ❑ Yes ® No
If yes, volume pumped: N/A
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)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
House built in 1984. Sytem is the original system according to Town of Barnstable records.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
72 Arrowhead Drive-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:.Subsurface Sewage Disposal System
Page 9of16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
72 Arrowhead Drive
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/02/08
Owner's Name Date of Inspection
Building Sewer(locate on site plan):
Depth below grade: 2.00 +/
feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Sewer pipe appears to be in good condition. No signs of leakage.
Septic Tank(locate on site plan):
Depth below grade: 0.75 +/-
I
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
Tank cover approximately 9" below grade.
if tank is metal, list age: N/A
years
Is age confirmed by a Certificate of Compliance?(attach a copy of ❑ Yes ❑ No
certificate)
Dimensions: 1,000 GALLON
Sludge depth: APPROX. 7"+/-
Distance from top of sludge to bottom of outlet tee or baffle
APPROX. 2"+/-
APPROX. 25"+/-
Scum thickness
Distance from top of scum to top of outlet tee or baffle APPROX. 15"+/-
Distance from bottom of scum to bottom of outlet tee or baffle APPROX. 14"+/-
How were dimensions determined?
MEASURED IN FIELD
72 Arrowhead Drive-T51NSP1.DOC.doc-11/2004 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
C. System Information (cont.)
72 Arrowhead Drive
Property Address
Hyannis MA 02601
Cityfrown State - Zip Code
Today Real Estate 02/02/08
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.):
Tank appears to be structurally sound, concrete tees are in place,water level in tank is at the invert of
outlet pipe.
i
Grease Trap(locate on site plan):
Depth below grade: N/Afeet
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
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 HoldingTank(tank must be pumped at time of inspection) locate on site plan):
P P P )( P )
Depth below grade: N/A
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
72 Arrowhead Drive-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 11 of 16
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cont.)
72 Arrowhead Drive
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/02/08
Owner's Name Date of Inspection
Tight or Holding Tank(cunt.)
Dimensions: N/A
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.):
Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert D-Box was dry.
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-Box is severley corroded and cover is cracked.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
72 Arrowhead Drive-T51NSP1.DOC.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- .
Page 12 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
72 Arrowhead Drive
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/02/08
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:
Type:
® leaching pits number:
1-1,0000 gal.
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leaching field appears to be working properly, no signs of ponding and vegetation is normal.
72 Arrowhead Drive-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 13 of 16
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
C. System Information (cont.)
72 Arrowhead Drive
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today real Estate 02/02/08
Owner's Name Date of Inspection
Cesspools(cesspool must be pumped as part of inspection)(locate on site plan):
Number and configuration N/A
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction: N/A
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
72 Arrowhead Drive-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 14 of 16
i
Commonwealth of Massachusetts
' Title 5 Official Inspection Form
Not for Voluntary Assessments
Subsurface Sewage Disposal System Form
M
C. System Information (cunt.)
72 Arrowhead Drive
Property Address
Hyannis MA 02601
Cityfrown State Zip Code
Today Real Estate 02/02/08
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.
I � T
}� 6Acic C
f
►A � 33 �
C, = 16
CS
C,�
72 Arrowhead Drive-T51NSP1.DOC.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System
Page 15 of 16
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Not for Voluntary Assessments
ug
Subsurface Sewage Disposal System Form
l
C. System Information (cont.)
72 Arrowhead Drive
Property Address
Hyannis MA 02601
Cityrrown State Zip Code
Today Real Estate 02/02/08
Owner's Name 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:
❑ Checked with local excavators, installers-(attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Barnstable GIS Groundwater Maps indicate high groundwater elevation is at approx. = 27'+/-,t GIS
Contour Maps indicate that the ground elevation is approximately at elevation 60.0' +/- ,
approx. 33'+/-above the groundwater table.
72 Arrowhead Drive-T51NSP1.DOC.doc-11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-
Page 16 of 16
r
Town of Barnstable
OF 1HE T
. . . y�P`' ti� Regulatory .Services
snisrsreai E Thomas F. Geiler,Director
Mass.
039, � Public Health .Division
TED MA'S A .
Thomas McKean, Director.
.200 Main Street, Hyannis,MA 02601
Office: 50&862-4644 Fax:. 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system.in the future
nor does this Division agree with any technical observation s and interpretations
contained within,this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ca C
L
N co
TITLE 5 CD
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSME NTS 1%
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM C7°
ca
PART A r--
CERTIFICATION m
Property Address: 72 Arrowhead Drive
Hyannis
Owner's Name: Edesio Santos /7
Owner's Address:
Date of Inspection: 7
Name of Inspector:(please print) W i 1 1 i am _ . Rob' nson Sr.
Company Name: William E. Robinson .Septic Service
Mailing Address: P O Box 1 089
Centerville, MA
Telephone Number: (SOB l 77s-B776
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 the inspection.The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems.1301 a DEP
approved system inspector pursuant toSection 15340 of Title 5(310 CMR 15.000). The system:
y/Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 1 L, Date: `-!L 6 4
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatthvr
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 copics"ient to the buyer,if applicable,and the approxing
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: 72 Arrowhead Drive
Hyannis
Owner: Edesio Santos
Date of inspection; GIG —6
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ 1 have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CUR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
reps' ed.The system,upon completion of the replacement or repair,as approved by the Board of Health.will pass.
Answ r yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please
expla' .
e septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsoun exhibits substantial infiltration or exfiltration or tank failure is imminent_System will pass inspection if the
existing is replaced with a complying septic tank as approved by the Board of Health.
•A meta septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicatin that the tank is less than 20 years old is available.
ND expla :
Odservation of sewage backup
p or break out or high static water level in the distribution box due to-broken or
obstruct pipes)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approval I f Board of Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The s tem required pumping more than 4 times a year due to broken or obsut.-cted pipe(s).The system will
pass inspectio if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is a=%-cd
F�,4
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: 72 Arrowhead Drive
Hyannis
Owner: Rapsi o antes
Date of Inspection: . /-14-6 -6
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 f 'ling 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. 'ystem will fail unless the Board of Health(and Public Water Supplier;if any)determines that the
syst in 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 aseptic 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.
3. 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: 72 Arrowhead Drive
Hyannis
Owner: Edesio Santos
Date of Inspection: -a 4
D. System Failure Criteria applicable to all systems:
You riiust indicate"yes"or"no"to each of the following for all inspections:
Yes o
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
Lclogged 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%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 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%atrr
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 late 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.)
(Yes/No)The system fails.1 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 a considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000
gp
Yot must indicate either"yes"or"no"to each of the following:
(Th 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 surface drinking water supply -.
_ the system is located in a nitrogen sensitive area(Interim We Protection Area—IWPA)or a mapped
Zone 11 of a public water supply well
1 you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
-es"in Section D above the large system has failed.The u%mcr yr operator of airy large system considered a
s gnificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
1 .304.The system owner should contact the appropriate regional office of the Department.
4
Page 5 of i l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 72 Arrowhead Drive
Hyannis
Owner: Edesio Santos
Date of Inspection: /—/ —o
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No/
_ / Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in'the previous two week period?
t/ Have large volumes of water been introduced to the system recently or as part of this inspection?_
k/ _ 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:
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 CMR 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: 72 Arrowhead Drive
yannis
Owner: Edesio Santos
Date of Inspection: // 0'
FLOW CONDITIONS
RESIDENTIAL n
Number of bedrooms(design):. } Number of bedrooms(actual): Z
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms): .3 G.o
Number of current residents: 1 I
Does residence have a garbage grinder(yes or no):_Zvp
Is laundry on a separate sewage system(yes or no):/La [if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no):,&2
Water meter readings,if available(last 2 years usage(gpd)): 2005 - 74, 250
Sump pump(yes or no):Iv 2004
Last date of occupancy: �/G-
COMMERCIAL/I STRIAL
Type of establishme
Design flow(based n 310 CMR 15.203): gpd
Basis of design flo (seats/persons/sqft,etc.):
Grease trap prese t(yes or no):—
Industrial waste olding tank present(yes or no):_
Non-sanitary w to discharged to the Title 5 system(yes or no):—
Water meter re dings,if available:
Last date of o upancy/use:
OTHER(d scribe):
GENERAL INFORMATION
Pumping Records
Source of information: g 4. Q t4
Was system pumped as part of the inspection(yes or no):Ao
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
TygPOOF 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) -
_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 or no):JLD
6
Page 7 of I I
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOW1.1
PAItT C
SYSTEM INFORMATION(continued)
Property Address: 72 Arrowhead Drive
Hyannis
Owner: Edesio Santos
Date of Inspecilon:
BUILDING SE ER(locate on site plan)
Dcpdt below ad(
Materials of onstruction:_cast iron _40 PVC_other(explau►):
Distance fr m private water supply well or suction line:
Comment (on condition of juutts,venting,evidence of leakage,ctc.):
SEPTIC TANK:_�_/(Iocatc on site plan)
Depth below grade: t
Material of construction. Xoncrete metal fiberglass_pol)•edtylene
_othcr(explain) .
If tank is metal list age:— Is age conftnrted•by a Cenificate of Compliance(yes or no):
certificate) —(attach a copy of
, ,
Dimensions:
Sludge depth: 3 �/
Distance from top of sludge Iu buuom of outlet ice or banlc: 3v ,
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance (rein bottom of scum to bottom of outlet tee or baflle:
I low were dimensions determined:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid Icvcls
as related to outlet invert,evidence of leakage,etc.):
L L C� Cf t 4- �b l rL rL& d i� C. ('
GREASE TRAP:_(locate site plan)
Depth below grade:_
Material of construction: concrete metal fiberglass polyethylene _other
(explain):
Dimensions:
Scum thickness:
Distance from top of sctnn to top of outlet lee or baffle:_
Distance from botto 1 of scum to bottom of outlet tee or baMc:
Date of last pumpi g:
Conunents(on'p (ping recomniendatiuns,utlel and outlet tee or battle conditiu:t, structural integrity,liquid levels
' as related to out I invert,evidence of leakage,etc.):
r
7
'age 8 of I 1
OFFICIAL INSPECTION FORM -NOT Il Oil VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Arrowhead Drive
Hyannis
Owrncr: Ede i o Santos
Dote or lospcclloo: /L-64'
T1G11T or 1l0L 1NG TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth bclow gr dc:
Material of cot struction:_concrete_metal_fiberglass_polyethylene other(explau)):
Uirncnsions:
Capacity: allons
Design Flow: gallonstday
Alann present(ye or no):
Alarm level: Alarm in working order(ycs or no):—
Date of last pu ing:
Comments(co dition or Mann and float switches,ctc.):
DISTRIBUTION Lbox,ctc.):
if present must be opcncd)(locatc on site plan)
Dcpth of liquid I el et invcn:
Conunents(note f bnd distribution to outlets equal,an)-evidence of solids carryover,any evidence of
leakage into or ut o
PUMP CHAMBER (locate on site plan)
Pumps in working rder(yes or no):
Alamts in workin order(ycs or no): _
Contntents(nole ondilion of pump chamber,cunditiun of pumps and appurtenances,etc.):
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Arrowhead Drive
Hyannis
Owner: Edesio Santos
Date of Inspection: 1-1 -C—a te
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why:
Type//
bleaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
m Coments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
/ /GGC., 44— �� s l O A.p� peo�s� 6
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and co figuration:
Depth—top of quid to inlet invert:
Depth of solid layer.
Depth of scu layer:
Dimensions f cesspool:
Materials o construction:
Indication f groundwater inflow(yes or no):
Commen (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY:/s(note
(locate on site plan)
Materialnstruction:
Dimensi
Depth ofs:
Commen condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Y
}
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• 72 Arrowhead Drive
Hyannis
Owner: Edesio Santos
Date of Inspection: Z-'IA6Z/
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.
10
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Arrowhead Drive
Hyannis
i Owner. Edesio Santos
Date,of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water_/S feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
�Lst �lo�i,_s y �v ,visa
11
COMMONWEALTH OF MASSACHUSETTS :
.ExEC.vwvE,OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RRECEIVED
APR,,2 7 2003
TOWN OF BARNSTABLE
TITLE 5
.. .HEALTH pEPT::.':
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
:. ..-
SUBSURFACE SEWAGE DISPOSAL,SYSTEM FORM-. --
PART A
CERTIFICATION
MAP
Property Address: 72 Arrowhead Dr
2 I:
Hyannis PARCEL 1%O_ Z
Owner's Name: Jim Souza
Owner's Address: LOT
Date of Inspection: '!y— 6 —&3
Name of Inspector: (please print) Wi 1 1 i am E_ • Robinson Sr.
Company.Name William E. Robinson Septic Service
Mailing Address: P •O-'Box 1089
Centerville-: MA
Telephone Number: (5081 775-8776
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 the inspection.The inspection was performed based on my
trainingand experience.in the.propei function and maintenance of on site sewage disposal systems.1 am•.a DEP
approved system inspector.pucsuant to Sectiod.15.340 of Title 5'(310 CMR 15.000 The system: .
VP
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
/ Fails
Inspector.'s Sigiiature:. ► { • Date: �-- y'— 3
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health of
DEP)within 30 days of completing this inspection.if the system is a'shared system or bas 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 seat to the system owner and copies sent 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
S[JBSURFACE SEWAGZ DISPPOSA ART AYSTEM•INSPECTION
CERTIFICATION (continued)
72 Arrowhead Dr
Property Address:
Owner.
Date or Inspection:
Inspection Summary•'Check�A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
411,have not found any information which indicates that any of t e f ailur a debelo�v described in 310 CMR
15.303 of in 310 CMR 15.304 exist.Any failure criteria not
Comments:
B. stem Conditionally Passes:
ne 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:
ed(Y,N,ND)
in for the following statements.If"not determined"please.
Answer y s,no or not determin
explain.
Th septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally •
unsound, xhibits substantial infiltration or eAltration or tank failure is imminent:System wi14`pass inspection if the
existing is replaced with a complying septic tank as approved by the 13oard`of Health:
•A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicatin that the tank is less than 20 years old is available.
ND expl in:
bservation of sewage backup or break out or high static water level in the distribution box due to-broken or
obstruct pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
approva of Board of Health):.
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
ND a plain:
The system required pumping more than 4 hrnss a year due to broken or odd pipe(s).The system will
pass in Lion if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is ricmovt d
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: 72 Arrowhead Dr
..
Owner:
Date of Inspection:
C. Fu her Evaluation is Required by the Board of Health:
C ditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing t protect ublic'heal th.,s;afetY or the environment.
1. Syst will pass unless Board of Health determines iri_accordance with 310'CMR.I5.30X!)(b).t6at the
syste is not.functioning.in a manner which will protect public health,safety.and the environment:
C s ool or ri is within 50 feet of a surface water
_.P P `�' . _...
Ce spool or.p4vy is*it hir:50:feef 6f a bordering vegetated wetland or a halt marsh.
2. System II fail unless.the Board of Health(and Public Water Supplier,if any)determines,that the
system is.:fun,t'ioning in a manner that protects the public health,safety.and environment:
The stem has a se tic tank and soil abso tion system SAS and the SAS,is within 100 feet of a
Y . P. . rP Y (SAS)
surface w ter supply or* i6utaryto`a surface water supply.
_ The ystem 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 taiik`and SAS and the SAS is less than_100 feet but 50 feet or more fronl a
private water Lpply well'•.Method used to determine distance
"This system asses if the well water analysis,performed ata DEP certified laboratory, for coliform
:bacteria and vo stile 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 a triggered.A copy of the analysis must be attached to this form.
3. Other:
Vk
Page 4 of I 1 ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM.INSPECTION FORM_
CERTIFICATION.(continued)
72 Arrowhead Dr
Property Address:
Owner. 9
Date of Inspection: L�^ _G 3 - ..
D. Sy tem Failure Criteria applicable to all systems:.
You mu t indicate`des"or"no"to each of the following for all inspections: '
Yes No
ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ isc6rge or ponding of effluent to the surface of the ground or surface waters due to an overloaded'or
logged SAS or cesspool. : ` .
_ Itatic liquid level in the distribution box above outlet invert due town overloaded or clogged SAS of
cesspool
_ L* id depth in cesspool is less than 67 below invert, . available1. ,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
_ .Any portion of the,SAS,cesspool or privy is below high ground water elevation.
_ pny 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 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 from4pnvate anal
ysis,
supply well with no acceptable water quality analysis.[This.system passes if the well.water anal
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 peesence 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:]
(Y /No)The system fails.I have determined that one or more of the above failure criteria exist as
escribed in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of
lealth to.determine what will be necessary to correct the failure.
E. L rge Systems:a
To be considel�red a large system the system must serve.a facility..with a design flow o[10,000 gpd to I5,000
gpd-
You must indi ate either"yes"or"no"to each of the following:
(The followin 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
I — —
th system is within 200 feet of a tributary to a surface drutidng water supply
th system is located in a nitrogen sensitive area(interim Wellhead Protection Area-1WPA)or a mapped
Zo a lI of a public water supply well .
if you have an,wered"yes"to any question in Section E the system is co>lsa f>ury significant
Systeconsidered answered
"yes"in Secti n D above the large system has failed.The own oP�
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The s!stem owner should contact the appropriate regional office of the Department.
4
Page 5 of 11 '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEVYAGE DISPOSAL:SYSTEM.INSPECTION FORMII, _- ,
PART B r`.. .. :. . .. ._>....
CHECKLIST
72 Arrowhead `Dr
Property Address: Hyannis
Jim Souza
Owner. ..:.........�:............::...._�,_.... ... ,. :. _
Date of Inspection: a�3
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No j _.... .::.:.....
t_//Pumping information was provided by the owner,occupant,or.Board of Health;
v Were any of the system components pumped out in the previous two weeks 7 .
Has the system received normal flows*in the previous two week period?:: <, :, . :,.. •:.
L, ave 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) ...
i,,`_ Was the facility or dwelling inspected for signs of sewage backup
t/_ 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?
V_ Was the facility owner(and occupants if differerit'froin 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
li Existing information.For example,a plan at the Board of Health.
_L1 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(3)(b))
5
r
Page 6 of 11
ry
OFFICIAL.INSPECTION FORM.—NOT FOR.VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
SYSTEM INFORMATION
72 Arrowhead Dr <
Property Address: Hyannis
Jim Souza ;
Owner.
Date of Inspection: C/—09 - y3
FLOW CONDITIONS
RESIDENTIAL.
Number of bedrooms(design): Number of bedrooms(actual):
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 der(yes or
Is laundry on a separate sewage system(yes or no):Ao [if yes separate inspection required]
Laundry system inspected(yes or no):s1;0
Seasonal use:(yes or no):ti o
Water meter readings,if available last 2 ears usage dun¢: a4O.Z•. ...:
( Y (fp )).; �40 0 �..
Sump pump(yes or no):k vr'O 9 S
Last date of occupancy:
J u ova
COMMER6�IALRNDUSTRIAL T� M : �003 3 SQL/S
Type of establishment:
Design flow(b ed on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
Grease trap pre ent(yes or no):_
Industrial wast holding tank present(yes or no):—
Non-sanitary w ste discharged to the Title S system(yes or no):
Water meter re dings,if available:
Last date of oc upancy/use:
OTHER(des ribe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as paKof the inspection(yes or no):_
If yes,volume pumped: /y O Qallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
ptic 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tigbt tank —Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components,date installed(if know and source of information:
Were sewage odors detected when arriving at the site(yes or no): AQ
6
' Page 7 of I 1
OFFICIAL INSPECTI.ON FORM_NOT'FOR VOLUNTARY ASSESSMENTS.
SUJBSURFACE'SEWAGE DISPOSAL SYSTEM:.I . SPECTIQN FORM `. `- �'
PART C
SYSTEM INFORMATION:(continued)
72 Arrowhead Dr
Property Address: Hyannis
a i-M,
Owner:
Date of inspection: 4/ O of 03
BUILDM SEWER(locaie on site plan)
Depth below ade: ;
Materials of c nstructioi _cast iron _40 PVC ._other(explain):
Distance from private water supply well or suction line: -,
Comments(o condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:Zaoc
ate on site plan) "
Depth below grade:_
Material of construction: Vconcrete_metal_fiberglass_polyethylene
_other(explain)- .. .
If tank is metal list age:_ Is age confirmed-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 tee or baffle: , o
Scum thickness: ? ,•Z.'
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: Q!'°<_'6— C.u,L�
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,1'iquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP:_(locate on site plan).
Depth below gr
Material of cons ction:_concrete_metal_fiberglass polyethylene_other.
- (explain): _
Dimensions:
Scum thickness:
Distance from tol of scuwn to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to otutle(invert,evidence of leakage,etc.):
1
7
Page 8 of 1 I
OFFICIAL INSPEC.'TION'FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM'
PART C
SYSTEM-INFORMATION(continued):
Property Address:
Owner:
Date ' Inspection:12n
TIGHT or H DING TANK: (tank must be pumped at time of inspection)(locate on.site plan)
Depth below gra e: - g _�. Y Y
Material of cons coon: concrete. mewl fiber lass of eth lene other(explain):
Dimensions:
Capacit) allons
Design Flow: alit,
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(conditi Dn of alarm and float switches,etc.):
DISTRIBUTION BOX: — (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert:
to outlets equal,any evidence of solids carryover,any evidence o
Comments(note if box is level and distribution [ ..•
leakage into or out of box,etc:): I�
PUMP CHAMBER: (locate on site plan)
Pumps in working order(yes or no):
Alarms in working or
(yes or no):
Comments(note conditi n of pump chamber,condition of pumps and appurtenances,etc.):
8
Page 9 of I I
OFFICIAL INSPECTION.FORM-NOT.FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
72 Arrowhead Dr
Property Address: Hyannis
Jim Souza
Owner:
Date of Inspection: /
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type . 1
leaching pits,number:_
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions-
overflow cesspool,number:
innovative/alternative system .Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,
etc.): _
CESSPQOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number Id configuration: y
Depth—to of liquid to inlet invert:
Depth of sQ?lids layer:
Depth of stum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater 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 f construction:
Dimension :
Depth of s e lids:
Commentsl(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
4,
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: 72 Arrowhead Dr
1i Raj:
Owner: _
Date of Inspection: - -G`3
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.
8
jL
' 1
10
Page 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Arrowhead Dr
Hyannis
Owner. Jim Souza
Date of Inspection: q— —M
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record•If checked,date of design-plan reviewed:
Observed site(abutting property/observation hole within ISO feet of SAS)
✓Checked with local Board of Health-explain: ,-I )`6,C lyk, 193
Checked with local excavators,installers=(attach*documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
SOP
d
11
v A �.
UP
or
� Ln
o �
. � s
Cl
s
f I O
i.C: p
IG
j
Building Sketch
.Borrower Client Wellih ton.M._Barreto
Property Address 72 Amowhead Dr.
Ch Hyannis., _ _. . CountV Barnstable State MA Zip Code 02601-2449
-Lender Family Choice.Mort a e Corp.
' a
32.0'
Bath
Bedroom ❑ Kitchen
o'IT
0
04 N
• 4
Living Room
Bedroom
Comments:
ARA LALCtJILA� IOT`IS S"�M)utAFYIFING t74F �rEl[ EKU@M.UN�
breakdown Subto4alsg...`...'
GLIa First Floor 768.00 768.00 First Floor
24.0 x 32.0 768.00
I '
a •
i
TOTAL LIVABLE (rounded) 1768 1 1 Calculation Total(rounded) 768
Form SKT.BldSki—"TOTAL for Windows"appraisal software by a la mode,inc.—1-800-ALAMODE `� "�
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
M
AY-2 -91
t3LE
'TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 72 Arrowhead Dr.
Hyannis, MA
Owner's Name: Julia Wescott
Owner's Address: 4 Ti spaqui_n St_
Mi ddl PhLn MA
Date of Inspection:)
Name of Inspector: (please print) Wi 1 1 i am E_ • Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: (508) 775-8776
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 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
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: jrG ,� �� Date: f-116 J
f The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heatth''or
D )within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd r 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
autho ity. I I ,
Note and Comments
i
**** his report only describes conditions at the time of inspection and under the conditions of use at that
tim This inspection does not address how the system will perform in the future under the same or different
co itions of use.
T' le 5'Inspection Form 6/15/2000 page 1 x
1
h
Page 2 of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 72 Arrowhead Dr.
Hyannis
Owner: Westc-Mtt
Date of Inspection: 6 —%d O /
Inspection Summary: Check A,B,C,D or E!ALWAYS complete all of Section D
A.I-S stem Passes:
YY! I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. ystem Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
reps' ed.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Ans er yes,no or not determined(YXND)in the for the following statements.If"nor determined"please
exp ain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
ound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the
e isting 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
dicating that the tank is less than 20 years old is available.
1�D explain:
Observation of sewage backup or break out or high static water level in the distribution box due to-broken or
o structed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with
a,proval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
distributian box is leveled or replaced
explain:
The system required pumping more than 4 times a year due to broken or obstrttcted pipe(s).The system will
s inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is rtmovW
ND x ain:
i
I_
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 Arrowhead Dr_
Hyannis
Owner:
Date of Inspection: /A—07
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 fai ing to protect public health,safety or the environment..
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(l)(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
sy 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 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 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 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 72 Arrowhead D=.
Hyantis
Owner: Wes_cot
Date of Inspection: 1 O—O
D. System Failure Criteria applicable to all systems:.
You must indicate"yes"or"no"to each of the following for all inspections:
Ye 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
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 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.]
(Yes/No)The system fails. I have dete-mined 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.
Large Systems:
o be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
pd.
ou must indicate either"yes"or"no"to each of the following:
The 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 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
you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
es"in Section D above the large system has fined.The owner or operator of arty large system considered a
s gnificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
1 .304.The system owner should contact the appropriate regional office of the Department.
4
' I
Page 5 of 1 l
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 72 Arrowhead inr
Hyannis
Owner: Wescott
Date of Inspection:��J'�/6
Check if the following have been done You must indicate`yes"or"no"as to each of the following:
Yes .No
Pumping information was provided by the owner,occupant,or Board of Health
Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
L,l_ Was the facility or dwelling inspected for signs of sewage back up
Was the site inspected for signs of break out?
I
_✓_. 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:
Yes o
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(3)(b)J
5
r
Page 6 of 1 I
OFFICIAL INSPECTION FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 72 Arrowhead Dr.
Hyannis
Owner: Wescott
Date of Inspection:
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#of bedrooms): 3l D
Number of current residents: 2-
Does residence have a garbage grinder(yes or no):/Z O
Is laundry on a separate sewage system(yes or no):&d[if yes separate inspection required]
Laundry system inspected(yes or no):,C,b
Seasonal use:(yes or no):/ .,
Water meter readings,if available(last 2 years usage(gpd)): 2000 44 , 250 gal.
Sump pump(yes or no):It, v 1999 34, 500 gal.
Last date of occupancy: !E/U•—®
COM ERCIAIANDUSTRIAL
TypeIn
tablishment:
Desiw(based on 310 CMR 15.203): gpd
Basisesign flow(seats/persons/sgft,etc.):
Greap present(yes or no):
Induwaste holding tank present(yes or no):
Non- ary waste discharged to the Title 5 system(yes or no):
Wateer readings,if available:
Lastof occupancy/use:
OTH (describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped asp of the inspection(yes or no):
If yes,volume pumped:_gallons--How was quantity pumped determined?
Reason for pumping:
Ty "OF SYSTEM
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
obtained from system owner) ,
_Tight tank _Attach a copy,of the DEP approval
Other(describe):
Approximate age of all component a�>�led(if known)fin)an source of information:
Were sewage odors detected when arriving at the site(yes or no): O
�". 6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
I
Property Address: 72 Arrowhead Dr.
Hyannis
Owner: we--r-ni t
Date of Inspection: 5—1 b —B I
BUI DING SEWER(locate on site plan)
Dep below grade:
Mate ials of construction:_cast iron _40 PVC_other(explain):
Dis nce from private water supply well or suction line:
Cc mments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
I
Depth below grade: 0
Material of construction:_concrete_metal_fiberglass polyethylene
—other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate) c I
'Dimensions:
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: D
Distance from top of scum to top of outlet tee or baffle:
Distance,from bottom of scum to bottom of outlet tee or baffle:
How were dimensions determined: CSt;-�-- �•a
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of.leakage,etcV:
GR ASE TRAP:_(locate on site plan)
Dep � below grade:_
Mate 'al of construction:_concrete_metal_fiberglass polyethylene_other
(expla ):
Dimer sions:
Scum hickness:
Distan a from top of scum to top of outlet tee or baffle:
Distan a from bottom of scum to bottom of outlet tee or baffle:
Date f last pumping:
Co ents(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels
as rel ted to outlet invert,evidence of leakage,etc.):
Page 8 of l 1 '
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address::7 2 T r ,he a B
Hyannis
Owner: Wp C-r-at f
Date of Inspection:
T GHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
De th below grade:
Mat rial of construction: concrete metal fiberglass_polyethylene other(explain):
Dime sions:
Capa 'ty: gallons
Desig Flow: gallons/day
Alarm resent(yes or no):
Alarm evel: Alarm in working order(yes or no):
Date o last pumping:
Co nts(condition of alarm and float switches,etc.):
DIS RIBUTION BOX: (if present must be opened)(locate on site plan)
Dep h of liquid level above outlet invert:
Co ents(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
1 age into or out of box,etc.):
6
PUM CHAMBER: (locate on site plan)
Pump in working order(yes or no):
Alarm in working order(yes or no):
Co nts(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
i
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Arrowhead Dr.
Hyannis
Owner: Wescott
Date of Inspection: :f-1 d,—6 �
SOIL ABSORPTION SYSTEM(SAS): l locate on site plan,excavation'not required)
If SAS not located explain why:
Type
I eaching pits,number: 1
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Type/name of technology:
Comments(note condition of soil, signs of hydraulic.failure, level of ponding,damp soil,condition of vegetation,
etc.): I
/
.—
C SPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Num er and configuration:
Dept —top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dime ions of cesspool:
Materi ils of construction:
Indica ion of groundwater inflow(yes or no):
Co nts(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PR (locate on site plan)
M erials of construction:
D mensions:
�pth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
f �
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:72 Arrowhead Dr.
Hyannis
Owner: Wescott
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.
1
10
r
Page 11 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 72 Arrowhead Dr.
Hyannis
Owner: Wescott
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water_�feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
SJbserved site(abutting property/observation hole within 150 feet of SAS)
,/Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
• 11
W A PERMIT NO,
LOCATION SEWAGE
GoT '� �X2owGrCWp IfIX- / -9S�
VILLAGE
141
INSTALLER'S NAME i ADDRESS
nn
I�/7)C �EyC�GP/n�� �fJ;c�• --Q�a?7Z�c�. �owc��y
�Aily Q57y�y�cc c=
S UILDDE R OR OWNER
DATE PERMIT ISSUEDrllz
��_��
DATE COMPLIANCE ISSUED / ` �02- �3�1
Gc/il vC
i
`jov5 E
� Q�
'i_
(it ;rjll
No.--,=4-9��_ Yu.......J�d ....._
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
!......W ...........OF......C / i'Ln/ T/ ,3.L.�s................................. r,
,Apure#inn for 11ispoM Works Tonstrnrtinn Famit .,
Application is hereby made for a Permit to Construct (tiror Repair ( ) an Individual Sewage Disposal
System at:
. !fs ?� ..7a %.�t� .._../ �s------ -------------------- ......T .�....---.......------ --------.............--
Location-Address or Lot No.
--------------------------------------- ------
{/•�•, � OwneAr `� � Address
a - ..........� ✓-`=----------•....................................�. .....................
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms.__......:__Z..........................Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ___-•_•_.-_-•.--•_-____-._.. No. of persons............................ Showers ( ) — Cafeteria ( )
Q' Other fixtures -•--••---•-----•--------------- ---
W Design Flow............. 3. .........._..........gallons per person per day. Total daily flow.............. ..�_----------_-___--gallons. I)
R: Septic Tank—Liquid'capacityZo'R�-gallons Length._6'�t:'�....... Width. Diameter................ Depth.:s! 8`,. I
Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No......../.......... Diameter........ 0__.._. Depth below inlet.......4.......... Total leaching area...?—G....�Z...sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by....gPk✓ �.._.G�:..A -e—.e` ............... Date_A��_._8 /58_',c
--------------.
Test Pit No. 1....L_.:n.minutes per inch Depth of Test Pit.../S .`� Depth to ground water....T. .
GTq Test Pit No. 2...:............minutes per inch Depth of Test Pit.................... Depth to ground water"________-_-_-••-_--___.
Q+' -•-•-••-••••••.........-••-•••••-•••-•••••.....-•-•---••••••••-••••-•--•-•-•-•-•-•--•---•---•-•--••---••••.........................................................
O Description of Soil....... 3G" h✓o00�o/�2y 9�sv3 -So.c 341"--/a8'� - /Cv/ SG.
x sue" /oB"� '�" G ?._..5 ✓D % ......
U - --------- --------- •-------- --------- ••------•---^-r---------...--•-• -----•----•
/.
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 TlITLZ 5 of the State Sanitary e— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has a ssued e o o iealth.
Signed •.•-•• •••••. ...... ----- --- ----- ................. ......... ................................
' Date
Application Approved By... =Yk'?,� .:.`� --------------•-------•---•---------.
Date
Application Disapproved for the following reasons---------------------------------------------- ----------------------------------------------------------------
--------------------•---•-•-•----•----------------------------------------------------......------------.--••••••--••--•••-••-••-•-••••••---•••-••-•-•-•----•--•-------••------•••--•••----••••••--..---
Date
Permit No.----�Ll-- -!�I-,.;�------•-•------------------ IssuedL-------------------------------------------------------
Date
t _
THE COMMONWEALTH OF MASSACHUSETTS
-�- BOARD OF HEALTH
............ OW-Al..---.....OF..... �/
Appliration for Disposal Works Tonutrurtion Frrmit
Application is hereby made for a Permit to Construct (l.< or Repair ( ) an Individual Sewage Disposal
System at:
Location-Address or Lot No.
......................_.......................................................................... .................................................................................................
Ownesr r ` Address
...................................................................... ........•-•-••----•----------................_._.........
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms...........!...........................Expansion Attic ( ) Garbage Grinder ( )
`k Other—T e of Building .............. No. of ersons............__....__._...___ Showers
Pk YP g -------------- P ( ) — Cafeteria ( )
Otherfixtures ------------------------------------------------•------------•••------•-----•--•-•••-------••---.......•-------------••-..._......-•-........_.-•----
W Design Flow.............A.17..............._...._.gallons per person per day. Total daily flow............. ............--.--...gallons.
WSeptic Tank—Liquid capacity_/�-!o�..gallons Length_?'6`:._._ Width�'_�y Diameter................ Depth. ..I&I...
x Disposal Trench—No____________________ Width._...�...._._._.. Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No.-__---f----------- Diameter-------/---_--__- Depth below inlet................... Total leaching area.............__.__sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
a Percolation Test Results Performed by 4-?lr!�? C __._ - ",l................ Date�`:_'6,.../
-
Test Pit No. 1..._.4._Z.._.minutes per inch Depth of Test Pit... `..... Depth to ground water........
fTo Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
94 .---•----------- -----------•-•._.........-••------------.......------......---•---••••••-•••.........-----•-•-•-•----•--•--•-._..._•----...............-_..
D Description of Soil--••• " 34. ""lca8" "e'2>/?014vSG.-
---------- ---
W
--•------------------------------------------•-----•------------------•-------------------------------------------•--•-------------------•......--------------.........................--------------
V Nature of Repairs or Alterations—Answer when applicable...............................................................................................
----------------------------------------------------------------------•---------------------------....-----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITI., 5 of the State Sanitary e—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has e ssued'tby Be*� o o ealth.
SignedP................. ----- -------• ---------------------------
Application Approved B Date
PP PP Y = =m. '��.. 1 -��. -fi'ct
Date
Application Disapproved for the following reasons----------------------------------------------------------------------------------------------------------------
---------------------------------------------------------------------------------------------------------I-----•----•----•---•-------•-•----••-------•----•-----------•••••---------•--•---•------•-..••-
Date
PermitNo.---- - 1-5-(-----•-•-•••-•-------•••---- Issued-.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............�. c/ ...........OF.........1AA,A./.TRAG.6................................
Trrtifiratr of Tomplittnrr
THIS IS TO`CERTIFY, That th Individual Sewage Disposal System constructed (✓f or Repaired ( )
by................. '...............................r'-------�(LQw I -----------------•-•----------------•-----------------.........••..........................--
Installer
at--•--•••-•-•.--- r_(�O --------------------------------------------------------------------------------•--•.
has been ,installed in accordance with the provisions of TI T� 5 o The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.___ .................. dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. f
DATE...............................................1. -+ .'�� ----- Inspector..............t`'-- .•-----..._...--------------•--•......--•--••-••........
THE COMMONWEALTH OF MASSACHUSETTS
j� BOARD OF HEALTH 15
r�•�'?..:...................OF.......... --...............--------------•--•-•----•-•---•--....... t�
No......................... FEE.::-:? ......•-•.......
Disposal Works 011notrnrtion rnmit
Permission is hereby granted ----------------7_7 �-------------------------------•------- -------------
-........
................
------
to Construct ( or�Repair ( ) an Individu -----------•----•--
al Sewage Disposal System
at No........_f. c...?..f: P= )- ^ 'n
Street
as shown on the application for Disposal Works Construction Permit No._. _q mow?._,Dated..r_'�/..�-)L/V("..................
..................................................... ...........
....................................-
DATE. �`` �� Board Health
FORM 1255 A. M. SULKIN, INC.. BOSTON:-
O
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7 I eZ&N/ 7V D of I
LvNC. Bo�..vo o S,oa.
3741
zo
.LET � lh z
t� -�- f✓eLE � �3 O O �
S&;677G DisT L��Ic1,l (�
heapo s ea �wA,�e
3
35
P�Po3t-� �/z,v�w�►y I z4 t
�- --- - --- - - - -- -- -� �� 4$A'
I
Z-or '9
I
NoTGs— �ZE�1/,q 77v�vs B�S� one LOCATION
�.�' iY8¢
ASSL�.�-s" DRwM. SCALE . ZQ. . . . DATE ocT./ /f 6�q
PLAN REFERENCE . .� NG. .LoT. . .B: .
5/4�o ww 0A1
Book. /.. . . . . . . . .: . .¢� . . . . .
s .E. N
C� KELLEY w
No.26100 i CERTIFY THAT THE . .. ...... . ... .:
p�C'/STV- SHOWN ON THIS PLAN IS LOCATED ON THE GROUND
q��3U flVEy �1 AS SHOWN HEREON AND THAT IT CONFORMS TO THE
SETBACK REQUIREMENTS OF-THE TOWN OF
WHEN CONSTRUCTED.
DATE . . . . . . . . . . . .
REGISTERED LAND SURVEYOR•
TOP OF FOUNDATION
CONCRETE COVER
CONCRETE COVERS
3,4V e 4"CAST IRON�12I "MAX.
nor
OR SCHEDULE 40 12"MAX. '
P.V.C. PIPE 4"SCHEDULE 40 I?V.C.(ONLY)
PITCH I/4'PER.FT PIPE - MIN. LEACH
PITCH 1/4'PER.ET PIT' PRECAST
�INV�RT . a LEACHING
° �.5 INVERT INVERT e W �; PIT OR
EL••
°'• SEPTIC TANK EL ,4L /G blSt. EL4s'�/ • . >_ EQUIV.
° INVERT BOX Q ,r,
a; EL.9C,33 /Poo.. .. GAL. INVERT H
EL4 -P 3/4"TO II/2
$ IN
WASHED
w STONE
Es--
/o' DIA.
PROR LE OF GROUND WATER TABLE
SEWAGE DISPOSAL SYSTEM
NO SCALE
SOIL LOG WITNESSED BY :
DATE S-'G .8(98¢ TIME.!�?%. 5.!�?'>. SNP! Tcp�/, BOARD OF HEALTH
TEST HOLE I TEST HOLE 2
48 78 ? Y. • ENGINEER
ELEV. .
ELEV. .. . . . . . . . .
3t' s„ �„ k DESIGN DATA
e-
�.4s 78 NUMBER OF BEDROOMS
Hbv� TOTAL ESTIMATED FLOW . ,Z2o GALLONS/DAY
co,yrzs� . .
-Sd BOTTOM LEACHING AREA' 78„So
. SQ.FT. /PI�1C.R D,
" .39.78 SIDE LEACHING AREA �88-`��' , , , SQ.FT./ P1/47/ C:P.D.
GARBAGE DISPOSAL . N.qY< .(50.% AREA INCREASE)
SArlr.> TOTAL LEACHING AREA . .7,67.od .
SQ.FT
3S.7B PERCOLATION RATE_��. 7/41- 7)VO MIN/INCH
.!yd .WATER ENCOUNTERED LEACHING AREA PER PERCOLATION RATE .r'r��,. SQ.FT/C;p,D
NUMBER OF LEACHING PITS PTWi77/
APPROVED . . . . . . . . . . . BOARD-OF HEALTH 7w4. •� .D/= STDN6" D.�/ ,094,Z— ,S/per
DATE . . . . . . . .
AGENT OR INSPECTOR
�. H Of Mgss
. '.�'•`�;(N O/'/;� goy,
ED
DIT/ o `
w
ko.21100 Z
�f/�SS- STE.N/5. . � �4 G�:T>✓P e srnrt�e�ar
PETITIONER G`�26.� ,Q NOsun•+`•�/
No........L .......... F�s:.....z...............
THE COMMONWEALTH OF MASSACHUSETTS
E®AR® HEALTH
-:..........OF......... .... . ...................
Allpliratinn fear Moposa1 War s nitrnr$ian Vrrmit
Application is hereby made for a Permit to Constr c-t d....( ) o
r epL0.) an n ividual Sewage Disposal
Syst t ll2r/ • --- ---- . •-- -----••..........••.
ation-Address... ................................... .. _._._ .......
Ow r Address
�Wl ........ .•................................. ••••----•------•--......---•-..............
Installer Address
Q Type of Building Size Lot... feet
feet
U Dwelling IL No. of Bedrooms......... ._...Expansion Attic ( ) Garbage Grinder ( )
p, Other—Type of Building ............................ No. of persons.-.-_------_----_-__------ Showers ( ) Cafeteria ( )
C4 Other fixtures .-•-------------•-----•-----------'------•------•-----
allons per person per day. Total daily flow...........W Design Flow...................... ------ g� P P P Y• Y - - ---------------------gallons.
WSeptic Tank Liquid capacity gallons Length................ Widti ....-..-......-- Diameter------------.--- Depth---.-_--.-_-..:.
x Disposal Trench No..................... Wi t ..... ..... . ..� 1 Total leaching area..------.....--.....sq. ft.
3 Seepage Pit No. Diametee�w inlet--•..-.. l®® Total leaching area..-(r q. ft.
Z Other Distribution box ( ) Dosing tank ( )
W Percolation Test Results Performed by.......................................................................... Date.........................................
,4 Test Pit No. 1................minutes per inch Depth of Test Pit-------------------- Depth to ground water..--....--......--......
(3, Test Pit No. 2................minu`tes per inch Depth of Test Pit--................. Depth to ground water.---.-------_-_---------
...
O Description of Soil----- ------- .....
x ---------------- -
V .•----•-•••••-•------------••••-----------•----------••-•-••-•---.....................................-•••--•-•-••--•-•----••-•----•------•----•............----••-••------------
W
VNature of Repairs or Alterations—Answer when applicable................................................................................................
' -----------------------------------------------------------------------------------•-- ................................=.....................---------------------------------------------- -----
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance witli
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
tome ..................
o
PP PP Y
Da
Application Approved B . • •--Glr4iL � 1/ ........
Date• �
Application Disapproved for the following reasons:................................................................................................................
•-••••-•-----------------------------------------------------------------•--•-•-----------------------•.•-----------------------------------......-----------------------------------------------------
Date
PermitNo......................................................... Issued..........................................._..•-•---•---
Date
I
No........___t ---- FE,...... ,�.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD HEALTH
. { j a .. ."L OF.........1 ". .
/ roF/'�'. ."........... y "olafe t�'�5 ....................
Appliration for Uispusaf Works Tomitrurtion tIrrutit
Application is hereby made for a Permit to Const�ruct or Repair an Individual Sewage Disposal
Syst t: f
:...--
. j /r L tion-Address
i' Address
-- ----- �3. -• . ... . ... ............
--•-••--------•-•-•----------••---•--••--••-•-------------.._.._.__-••-•--•-•--•••-•---------••••.
Installer Address
Q Type of Building Size Lot...1_,2... '._:_Sq. feet
Dwelling'V _e
No.' of Bedrooms.--_---•�_______________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons---------------------_ Showers — Cafeteria
a' Other fixtures ............................
W Design Flow.....................�___:o............gallons per person per day. Total daily flow.......... ;;•.,_ _-.-_--gallons.
Septic Tank 4__Liquid capacity/ `_gallons Length................ Width.*--------------- Diameter................. Depth................
Disposal Trench—No_____________________ Width..............._. al Le h. __.__.... Total leaching area __ ------sq. f t.
3 Seepage Pit No._1-.............--- Diameter i/t` ! � f�l `� to et_._:_....... _-__ Total leaching area_. e�"'sq. ft.
Z Other Distribution box ( ) Dosmg tank ( )
aPercolation Test Results Performed bY............................................................................. Date---------------------------------------.
Test Pit No. 1................minutes per inch Depth".of Test Pit.................... Depth to ground water........................
Gr, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
W _
®-______-_- _. _ ' __)_____
x
O Description of Soil..... .
U ..--•-------------------------------------------••-••=
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 in
operation until a Certificate of Compliance has been issued by-the board of.health.
i 'a
t"
Application Approved BY PP PP .r !�
A < f V.0 Date
Application Disapproved for the following reasons:................................................................................................................
.........................................................................................................................................................................................................
Date
Permit No.................... Issued
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.... ,s.�_r ......../-..
priifirtt#r of Tootptiatta
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�) or Repaired ( )
by--------------------•••••---•-•••---••-•••--••----•----•••••--- - - -- _--- -------•-------•------------------------------------------------•--------------
�a� " I`taller
-•-•-•-•-----------------••--..._••---
has been installed in accordance with the provisions of Article X 44
oYThe State Sanitary Code s described i the
application for Disposal Works Construction Permit No.............................Y__ dated--------- 1:. .......
THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE._::.3 -.7- 77 B................................................... Inspector---------------------------•-•--------------------------------------......----•----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O HEALTH
t � ee
.. ........O F..... :s.�`. .
No........f ----------- FEE .......
�i��.o,�ttl or�� C�on,>�$rttriiort 1'rittti# �• •�
,cPermission is hereby granted---------- ------------------------------------------------------------
to Con tr ( rrly2ep •h ) an Indiyi'dual ewag • isP0.sal System .
at No ---- =
<^ _ See - ,
as shown on the application for Disposal Works Construction• P }t No. _._ _. ated.... ------
�� E•, Board of ealth
DATE---- ............................•_--•--
FORM 1255 HOBBS & wA-RREN. INC...PUBLISHERS