HomeMy WebLinkAbout0091 ARROWHEAD DRIVE - Health 91 ARROWHEAD DR., HYANNIS
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Commonwealth of Massachusetts '
Title 5 Official Inspection Form t
(I. Subsurface Sewage Disposal System Form -Not for Voluntary Assessments j
X
91 Arrowhead Drive h.A
u—
Property Address +.
Karen Kold
r Owner Owner's N
information is +
required for every Hyannisam Ma 02601 11-24 2020
page. Cityrrown State Zip Code Date of Inspection
{
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form. _
Important:When filling out forms A. Inspector Information C
3
on the computer,
use only the tab, Brett Hickey
key to move your Name of Inspector
cursor-do not B&B Excavation
i use the return key. Company Name
374 Route 130
h+ Company Address
Sandwich Ma 02563
City/Town State Zip Code
1;eYv; (508)477-0653 S113747
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5
(310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address
listed above;the information reported below is true, accurate and complete as of the time of my -
inspection; and the inspection was performed based on my training and experience in the proper function
and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined
that the system:
1. ❑■ Passes
2., ❑ Conditionally Passes `
' t
3. ❑ Needs Further Evaluation by the Local Approving Authority
4. ❑ Fails
Brett H i cke i Digitally sgnO by 8,0 Hickey ♦ .
Y Date:2020.1i.So08:ta:19-0s•oo. 11-24-2020
t
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of.
10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate i
regional office of the DEP. The original form should be sent to the system owner and copies sent to
the buyer, if applicable, and the approving authority.
• � y,7. !+ .�•, y4�,j yr
Please note: This report only describes conditions at the time of inspection and under the+'
s; t 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.
w
r
', t51nsp doc rev.7/26/2016'� '+ < Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 16 t ? _ _
Commonwealth of Massachusetts
- -_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
91 Arrowhead Drive
Property Address
Karen Kold
Owner Owner's Name
information is Hyannis Ma 02601 11-24-2020
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary
i
Inspection Summary: Complete 1, Z 3,or 5 and all of 4 and 6.
I
1) 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: '
The system was in working order at the time of inspection.
2) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
15insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18
I
I
I
L
Commonwealth of Massachusetts
—I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Arrowhead Drive
Property Address
Karen Kold
Owner Owner's Name
information is Hyannis Ma 02601 11-24-2020
required for every Y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
2) System Conditionally Passes(cont.):
❑ Pump.Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms,are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
i
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
1
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3) 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.
a. 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: '
15insp.doc rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18
Commonwealth of Massachusetts ,
Title 5 Official Inspection Form
is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Arrowhead Drive
Property Address
Karen Kold
Owner Owner's Name
information is required for every Hyannis Ma 02601 11-24-2020
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cant.)
❑ Cesspool or privy is wit-iin 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
b. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
c. Other:
4) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following'for all inspections:
Yes No
❑ El clogged
of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ 0 Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
t5insp.doc•rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18
Commonwealth of Massachusetts
I Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Arrowhead Drive
Property Address
Karen Kold
Owner Owner's Name
information is Hyannis Ma 02601 11-24-2020
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
Static liquid level in the distributiorY box above outlet invert due to an overloaded
❑ El or clogged SAS or cesspool
❑ ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less
than '/z day flow
❑ ❑ Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ 0 Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ Q 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 water supply
well.
❑ El Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ n Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from,a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
! provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
!
❑ 0 The system is a cesspool serving a facility with a design flow of 2000 gpd-
10,000 gpd.
❑ F 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.
5) 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 CA.
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
rElArea—IWPA)or a mapped Zone II of a public water supply well
t51nsp.doc•rev.7/26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 - --
l
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
u
91 Arrowhead Drive
Property Address
Karen Kold
Owner Owner's Name
information is Hyannis Ma 02601 11-24-2020
required for every y
page. City/Town State Zip Code Date of Inspection
C. Inspection Summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant
threat,or answered"yes"to any question in Section CA above the large system has failed.The
owner or operator of any large system considered a significant threat under Section C.5 or failed
under Section CA shall upgrade the system in accordance with 310 CMR 15.304.The system owner
should contact the appropriate regional office of the Department.
t
6. You must indicate "yes" or"no"for each of the following for all inspections:
Yes No
❑ 0 Pumping information was provided.by the owner, occupant, or Board of Health
❑ El Were any of the system components pumped out in the previous two weeks?
❑ El 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)
❑ El Was the facility or dwelling inspected for signs of sewage back up?
El ❑ Was the site inspected for signs of break out?
El ❑ Were all system components,excluding the SAS, located on site?
El ❑ 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?
❑ Q 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:
0 ❑ Existing information. For example,a plan at the Board of Health.
❑ a Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18
Commonwealth of Massachusetts
r�- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Arrowhead Drive
Property Address
Karen Kold
Owner Owner's Name
information is Hyannis Ma 02601 11-24-2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
4' Number of bedrooms(design): Number of bedrooms(actual): 3
440/GPD
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):
Description:
0
Number of current residents:
Does residence have a garbage grinder? ❑ Yes Q No
Does residence have a water treatment unit? ❑ Yes Q No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes 0 No
information in this report.)
Laundry system inspected? ❑ Yes 0 No ,
i
Seasonaluse? ❑ Yes No
See below
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2019- 248,000gallons 2020- 176,528gallons
Sump pump? ❑ Yes .❑■ No
Last date of occupancy: 10-2020Date ,,
". 151nsp.doc•rev.7/26/2018• Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
_ — Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Arrowhead Drive
u Property Address
Karen Kold
Owner Owner's Name
information is Hyannis Ma 02601 11-24-2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/industrial Flow Conditions:
NA
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to:
Industrial waste holding tank present? ❑ 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 below):
I
3. Pumping Records:
Source of information: Owner-date of last pump is unknown
Was system pumped as part of the inspection? ❑ Yes ❑■ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
t5lnsp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
r- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments r
91 Arrowhead Drive
Property Address
Karen Kold
Owner Owner's Name
information is Hyannis Ma 02601 11-24-2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
j
El Septic tank, distribution box,soil absorption system
❑ Single cesspool .
❑ Overflow cesspool
❑ Privy
t
❑ Shared system (yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed(if known)and source of information:
1996 per permit
Were sewage odors detected when arriving at the-site? ❑ Yes ❑■ No i
5. Building Sewer(locate on site plan):
3'
Depth below grade: feet
Material of construction:
❑ cast iron ❑■ 40 PVC ❑other(explain):,
Town water
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting, evidence of leakage, etc.): .-'
t51nsp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18
I +
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Arrowhead Drive
V
Property Address
Karen Kold
Owner Owner's Name
information is Hyannis Ma 02601 11-24-2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
6. Septic Tank(locate on site plan):
21
Depth below grade: feet
Material of construction:
❑■ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate ofCompliance? (attach a copy of certificate) ❑ Yes ❑ No
1
Dimensions: 000gallons
1211
Sludge depth:
2411
Distance from top of sludge to bottom of outlet tee or baffle
611
Scum thickness
211
Distance from top of scum to top of outlet tee or baffle
1211
Distance from bottom of scum to(bottom of outlet tee or baffle
measured
How were dimensions determined?
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet irvert,evidence of leakage, etc.):
The tank was in working order at the time of inspection. The tank is in need of pumping
at this time and should be pumped every two years for maintenance.
15insp.cloc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Arrowhead Drive
Property Address
Karen Kold
Owner Owner's Name
information is Hyannis Ma 02601 11-24-2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (Cont.)
7. Grease Trap(locate on site plan):
NA
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
L
8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
NA
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow: `
gallons per day it.
151nsp.doc-rev.7/262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 ,
Commonwealth of Massachusetts
-, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Arrowhead Drive
U Property Address
Karen Kold
Owner Owner's Name
information is Hyannis Ma 02601 11-24-2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
Alarm.present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
9. Distribution Box(if present must be opened) (locate on site plan):
Or'
Depth of liquid level above outlet invert
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.):
The d-box was in working order at the time of inspection.
t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Arrowhead Drive
Property Address
Karen Kold
Owner Owner's Name
information is Hyannis Ma 02601 11-24-2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): t
' NA
r
* If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
❑ leaching pits number:
(4) 500 gallon
El leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
' ❑ leaching fields number,dimensions:
❑ •
overflow cesspool number:
❑ innovative/alternative system .
Type/name of technology:
151nsp.doc-rev.7l26l2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18
_ I,
Commonwealth of Massachusetts
- - Title 5 Official Inspection Form
27 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Arrowhead Drive
V*'
Property Address
Karen Kold
Owner Owner's Name
information is Hyannis Ma 02601 11-24-2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
The SAS was in working order at the time of inspection. Leaching was dry when viewed
i
with no evidence of past backup.
12. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan):
NA
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•page 14 of 18
Commonwealth of Massachusetts
l Title 5 Official Inspection Form
(u � Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
............ <
91 Arrowhead Drive
Property Address
Karen Kold
Owner Owner's Name
information is Hyannis Ma 02601 11-24-2020
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
13. Privy(locate on site plan):
Materials of construction: NA
Dimensions
I
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
i
i
t5lnsp.doc•rev.7/262018 Title 5 OfBdal Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18
j
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Arrowhead Drive
Property Address
Karen Kold
Owner Owner's Name
information is Hyannis Ma 02601 11-24-2020
required for every Y
page, CitylTown State Zip Code Date of Inspection
D. System Information (can:.)
14. Sketch Of Sewage Disposal System:
Provide a view 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. Check one of the boxes below:
❑■ hand-sketch in the area below
❑ drawing attached separately
u�sr..�,,xtz•s:rlatyts.�..E+.�no):ri5.evo_�` .. ,..
3Fii!!'><I4-TANK CAI.ACt'!Y GAc t.` .. .. . z.
• .1:8AGJiZivO PAGQ-T['Yq CO•P°J', ti�0 47r,7D.a'..�c,�lc. (aL�ra) '`'�' _..
�V7ZlDE'IZ OR:'OWNBR ''-t�'�:�.5''C'•••�=.Lv�.� M:s'� .
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1PEt3TrfP4`ESA'LE+: "C Z.-i.:S ALm "+COMt•LIANC'8-DA78:,
saparancon L7If4Y=e 19atWe n:tne:
IVlvximu.n Ac/jusYocl t7noanrd wbtc:''Ihb7t: .. ..� ....-. ,...
Riva*"Watee Supply Well arul Laact+lrag"Racility,.(lt.any.wclls:exfst, s�:.'.� W► PbeK..
tan sited MHtlua 200 lroct..o[I®ecAiag frwiuty>
'BAtgc of Wftt.tand and'.L.mnatiing.Vt Wty([F any wetlands exAst _
wlikdn 300 feet otf.l�aonching�r.,,fa'c4tity). t�7 11 nir. 'Peet
Furnished by: '1�`wi �^"`f�
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Ail- 4 51
t51nsp.doc•rev.7/26/2018 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
—< Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Arrowhead Drive
Property Address
Karen Kold
Owner Owner's Name
information is required for every Hyannis Ma 02601 11-24-2020
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
i
❑■ Check Slope
❑■ Surface water
❑� Check cellar
❑■ Shallow wells
No GW 4' below SAS
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
El Obtained from system design plans on record
Field card dated 4-22-1996
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
I
I
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Information on file at the local Board of Health was used to determine high groundwater.
4. ;
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5lnsp.doc•rev.7/26/2018 ,. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18
t
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_._ . Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
91 Arrowhead Drive
Property Address
Karen Kold
Owner Owner's Name
information is required for every Hyannis Ma 02601 11-24-2020
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
❑■ A. Inspector Information: Complete all fields in this section.
�■ B. Certification: Signed &Dated and 1, 2, 3, or 4 checked
❑■ C. Inspection Summary:
1, 2, 3,or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
❑■ D. System Information:
For 8:Tight/Holding Tank—Pumping contract attached
For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 15: Explanation of estimated depth to high groundwater included
t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18
III
.k
COMMONWEALTH OF I,L-�SSACHUSETTS
E\ECL'TI\rE OFFICE OF ENVIRONI4ENT. AFfF.MRS d
DEPARTMENT OF ENVIRONMENTAL PR : TIONPtelVEO
ONE CRZNTER STREET.. BOSTON MA 0210t (61 1 2.42 Q1
.. =� 'SAY 1 8 1999
TOH'NOFggA
%0 'fkTHDfPj TR '9Y COXf
Secretar,
ARGEO PAUL CELLUm A = B STRUH!
Governor E Coromissione:
�p to SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
tAKe ".2-71 PART
Lo-_ 0S 7 Q `^ CERTIFICATION
Property Address: 11 tt�Q�`�►JL- Name of Owner ,.
4 \Z� Address of Owner: 1��z� �T3=. C, -'L
VLck
Date of Inspection:
Name of Inspector:(Please Prirrt)
I am a DEP approved system inspector pursuant to Section 15.r340 of True 5 1310 CMR 15.000)
Company Name: ram[ r*&-it ir Ek L^�e-,t�t.Se J.+CA F
IJlazng Address:? . L-z 7?to }� s�p�r ty o�4-`7
Taleplwne Number: �SQ�-.�(t ,z. /ft e__p
CERTIRCATION 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 Lag of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
_ Needs Further Evaluation Ay the Local Approving Authority
Fails
Inspector's Signature: Date: .
The System Inspector shall submit a copy of this inspection report to the,Approving Authority (Board of Health or DEP)within thirty (30)days of
completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
revised 9/2/98 Page Iof11
.0. Pnnted on Recycled Paper
CONIMONwEALTH OF RL-%SSACHUSETTS
El-ECUTIVE OFFICE OF E\VIRON;,IENTA.L. AFF.MI:S
_ r DEPARTMENT OF ENVIItONMENTAL TROTECTION
ONE X\INTER STDrET. BOSTON M-A 0210r (6iil 292:,5011
TRUDY COX}
Secretar
AIRGEO PAUL CELLUCCI DAVID B STRL•H:
Governor Commissioner
SUBSURFACE SEWAGE'DISPOSAL SYSTEM'INSPECTION FORM
PART A
j CERTIFICATION
Property Address: -11 �i I�.QS.`�U �— Name of Owner LcAu„A } a rA '_!_ `Ao&.3
Address of Owner: \, sy� Qck
Date of Inspection:
j Name of Inspector:(Please Print) •C_fr ECG U
I am a DEP approved system inspector pursuant to Section 15.340 of ride 5(310 CMR 15.000)
Company Name: 4&rty �,r 10� k y.�ni a, fto e, L4+u Cl
Maim Address:_7Q dgn. ( L-g 211,
Telephorne Number:
CERTIFICATION STATEMENT
1 certify that 1 have personally inspected the sewage disposal system at this address and that the information reported below is true• accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
Passes
Conditionally Passes
Needs Further Evaluation y the Local Approving Authority
Fails
Inspector's Signature: Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty (30)days of
completing this Inspection. If the system is a shared system or has a design flow of 10.000 gpd or greater,the inspector and the system owner
shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the
system owner and copies sent to the buyer,if applicable, and the approving authority.
NOTES AND COMMENTS
i
I
I
I
revised 9/2/98 Pete IofII
-iJ Prmud on R"w'd Paper
I ,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued) '
Property Address:
Owner:
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determ/theem is failin; to protect the
public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a s It marsh.
j
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF,ANY)DETERMINES THAT THE SYSTEM IS
FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system,SAS)and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply. ,•'
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analisis for eoliform bacteria and volatile organic compounds indicates that the
well is free from pollution from that facility and thb presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm. Method used to determine distance (approximation not valid).
31 OTHER
i
revised 9/2/98 Page 3oru i
• j
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
property Address:
Owner:
Date of Inspection:
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as d/ckgged
0 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to t will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an overloed SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surfa to an overloaded or clogged SAS o,
cesspool.
Static liquid level in the distribution box above outlet invert due to 7 clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less tnan 1/2 day flow.
Required pumping more than 4 times in the last year NOT due t logged or obstructed pipe(sl.
Number of times pumped_.
Any portion of the Soil Absorption System, cesspool or prj is below the high groundwater elevation.
Any portion of a cesspool or privy is with•n 100 feet of rjrsurface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of,/public well.
Any portion of a cesspool or privy is within 50 feet
t.of a private water supply well.
Any portion of a cesspool or privy is less-than 106 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well hal been analyzed to be acceptable, attach copy of well water analysis for
•coliform bacteria,volatile organic compounds,immonia nitrogen and nitrate nitrogen.
E. LARGE SYSTEM FAILS: /
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow bf 10.000 gpd or greater(Large System)and the system is a significant threat to publi
health and safety and the environment becauss one or more of the following conditions exist:
Yes No
the system is within 400 feet 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 trogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such syste shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
office of the Department for further intor ation.
revised 9/2/98 Page 4of11
1 , • • 1
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: `` �`4��►�", t
Owner:
Date of Inspection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_ Pumping information was provided by the owner, occupant. or Board of Health.
None of the system components have been pumped for at least two weeks and-the system has been-receiving normal flow
rates during that period. Large volumes of water have not been introduced into the system recently or as part of this
inspection.
_ As built plans have been obtained and examined. Note if they are not available with N/A.
_ The facility'or dwelling was inspected for signs of sewage back-up.
X _ The system does not receive non-sanitary or industrial waste flow.
The site was inspected for signs of breakout.
_ All system components, excluding the Soil Absorption System, have been located on the site.
_ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles
or tees, material of construction, dimensions,depth of liquid,depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
Existing information. For example. Plan at B.O.H.
Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
(15.302(3)(b))
The facility owner(and occupants,if differera from owner)were provided with information on the propermaintenanco-0f
SubSurface Disposal Systems.
revised 9/2/98 Page 5or»
-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART C
SYSTEM INFORMATION
�n n
'roperty Address: 9( III,ES. L
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: u g.p.d./bedroom.
Number of bedrooms (design): Number of bedrooms (actual):'034
Total DESIGN flowlQ_
Number of current residents:
Garbage grinder(yes or no):_L-�,
Laundry(separate system) 1 es or not: tJ: If yes. separate inspection.required
Laundry system inspected ye or no)
Seasonal use (yes or no): S
Water meter readings, if ava table (last two year's usage(gpc:): 1�
Sump Pump(yes or no): P
Last date of occupancy:—Zn&Qt-,T S'uv.�,rtt,�} w%eoCE%i.4�s
COMMERCIALANDUSTRIAL:
Type of establishment:
Design flow: opd ( Based on 15.203)
Basis of design flow
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings,if available:
Last date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
CA-
System pumped as part of inspection: (yes or nol_tt�0
If yes, volume pumped: gallons
Reason for pumping:
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records,if any)
I/A Technology.etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed(if known)and source of information: — `Q
Sewage odors detected when arriving at the site: (yes or no)
i
j revised 9/2/98 Page 6of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address:
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:_
Material of construction: _cast iron_40 PVC_ other (explain)
Distance from private water supply well or suction line
Diameter
Comments: (condition of joints. venting, evidence of leakage.-etc.)
SEPTIC TANK: l�
(locate on site pi n)
Depth below grade: k
Material of construction:1concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal, list age_( Is age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: ,33q
Sludge depth: mil`^
,,. Distance from top of sludge to bottom of outlet tee or baffler
Scum thickness: 6 'ADistance from top of scum to top of outlet tee or baffle: �? , �t
,. Distance from bottom of scum to bottom of outle tee or baffle:_
How dimensions were determined:
:omments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in rela ' n o outI invert, str ctural' tegrity,
evidence of leakage,etc.) 2� F�
cli
�.1 V
VC
GREASE TRAP: tLf.:,'
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal Fiberglass _Polyethylene_other(explain) ,
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage,etc.)
I
revised 9/2/98 , Page 7ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
4roperty Address:
Owner:
Date of Inspection:
TIGHT OR HOLDING TANK: Y (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal_Fiberglass_Polyethylene other(explain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm present
Alarm.level: Alarm in working order:Yes _ No_
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches,etc.)
DISTRIBUTION BOX: S
(locate on site plan)
Depth of liquid level above outlet invert: uu(GOTZ,tT
Comments:
note if evel and distribution equal, evidence of solids arryover vidence of leaka a into or out of box, etc.) -
(2a Ld-u(uju(
PUMP CHAMBER:
(locate on site plan)
Pumps in working order:(Yes or No)
Alarms in working order(Yes or No)
Comments:
(note condition of pump chamber,-condition of pumps and appurtenances,etc.)
re / /wised 9 2 98 Page 8of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Iroperty Address:
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):
(locate on site plan, if possible: exca lion not required.location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits. number:_
leaching chambers, number:�YSc(?k -Qy{v-xAks
leaching galleries. number:_
leaching trenches• number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note condition of soil, signs of h Z draulic failure, level of pondin damp il, dition�oof vegettaatm�etc.) 1 }�
�. t
•
CESSPOOLS: A )
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Iepth of scum layer:
Dimensions of cesspool:
Materials of construction:
!u Indication of groundwater:
inflow(cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
PRIVY:1�2
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
i
revised 9/2/98 Page 9of11
w i7 I
SUBSURFACE SEWAG=DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
"roperty Address: q1
)wner:
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
�J
1� 2
3 �
-
�� Lj
revised 9/2/98 PaR�to of u
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
,operty Address: O� �
Owner:
Date of Inspection:
NRCS Report name
Soil Type_ — ------ — -
Typical depth to groundwater_____ __ __
USGS Date website visited r0
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope5k,cAr
Surface water fad
Check Cellar
Shallow wells t�y�
Estimated Depth to Groundwater ,Feet
Please indicate all the methods used to"determine High Groundwater Elevation:
Obtained from Design Plans on record
Observed Site(Abutting property, observation hole. basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
s
Checked pumping records
_Checked local excavators. installers
Used USGS Data
Describe how you•established the High Groundwater Elevation. (Must be completed)
revised 9/2/98 Page 11of11
_ 1 TOWN OF BA.RNSTA.BLE _ g
LOCAIJON 91 ,�r�ow_ e��/ ��• SEWAGE # l6 6
VILi AGE /r y�f1/l d.,� ASSESSOR'S MAP & LOTZZI 0T
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY- I,4go G,L
LEACHING FACILITY: (type)SW C+d L-rva'a Cgur/�r�y� (size)/6YY n Ve X.?
NO.OF BEDROOMS y
BUILDER OR OWNER �Zes,4wd
PERMITDATE: a�/l0� COMPLIANCE DATE: "
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Sf Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) IVA Feet
Furnished by
Z swu7�i y���
C`� Vd� ` Ywa�V
e= = �
W
Q
1
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gNo. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppYication for Mis�pozal *pgtem Construction Permit
Application is hereby made for a Permit to Construct( )or Repair(/an On-site Sewage Disposal System at:
Lo ation Addrcss or Lot No. Owner's Name,)Iddress and Tel.No.
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Garbage Grinder( �
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 4/-11O gallons.
Plan Date Number of sheets Revision Date
Title
Description of Soil
Nature of Repair or Iterations(Ans er when applic ble) .�
�s utroazle , i v 3 2&le,s <Ape P re e-Xi 5 2tLoA le" gal s��c
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issu is ar Health.
Signed Date
Application Approved by
Application Disapproved for the following reason
Permit No. Date.Issued 119
�...'`"r' ��.. ,.�..r .....�..-s T..., _Y� . ... .. )�.. r: �; __,r ._• .._ s .. ._._ �. _ . .. ' t ,'ice- .. i."`-'`v,:
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS _
{ PUBLIC HEALTH DIVISION` TOWN OF BARNSTABLE;MASSACHUSETTS
01pprication for �Bigpoga[,*pgtem (fongtruction Permit
Application is hereby made for a Permit to Construct( )or Repair(/an On-site Sewage Disposal System at:
Location Ad r�ss or Lot No. Owner's Name,Address and Tel.No.
TOM ��9josri�o TOin D '•f�os�`I ao f
q) A�^�®Gt/�iep�A /! gnni S 3"6`l-6 35
Installer's Name,Address,and Tel.No. 71 Designer's Name,Address and Tel.No.
u4it 8 D
Type of Building: 'J
Dwelling No.of Bedrooms�N Garbage Grinder(�e
Other Type of Building KeS%�cNGG No. of Persons Showers( ) Cafeteria( )
I Other Fixtures j
f
Design Flow l/!7 r gallons per day. Calculated daily flow y'yO gallons.
Plan Date t Number of sheets Revision Date
Title
Description of Soil
Nature of Repairs or Alterations(Ans er when applic ble) -gyp y' S`Oogq/ ��Q�j.�q Gyri�l i's•
S ll!/'DUrIGrP �� d �D
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to*place the system in operation until a Certifi-
cate of Compliance has been issu is ard, Health. /
Signed Date �� 6
Application Approved by a
Application Disapproved or the following reaso
Permit No. aQ Date Issued 657
f
THE COMMONWEALTH OF MASSACHUSETTS 7l—
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System installed( )or repaired replaced(Peron
by 6 OfA040 G S for
as / ✓YOlc/ B �', en constructed in accordance -
with the provisions of Title 5 and the for Disposal S stem Construction Permit No. dated
Use of this system is conditioned on compliance with the provisions s h below:
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Migpogal bpgtem Congtruction Permit
Permission is hereby granted t AO/7f000/,*/ GQrl6/ ,
to construct( )repair( n On-site Sewage System located at 9/ �r'raa. �m ��'�
/er ny 1,5
and as described in the above Application for Disposal System Construction Permit.The applicant reco nizes his/her duty to
comply with Tid 5 and the following local provisions or special conditions.
All constructio must e c pleted within two years of the date below. !� o
PP Y
Date: Approved b /l`"
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
W01110 CONSTRUC UION PERMIT(WITHOUT DESIGNED PLANS)
(, 0-, ,�O/�;yd��ereby certify that the application for disposal works
construction permit signed by me dated `10 Q� , concerning the
property located at Ilew , meets all of the
following criteria:
:�Tficrc
here arc no wetlands within 300 feet of the proposed septic system
arc no private wells within 15o feet of the proposed septic system
he observed groundwater table is 14 rat or greater below the bottom of the leaching racility
yhere is no increase in flow and/or change In use proposed
�•//There are no variances requested or needed.
SIGNED: DAM
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
iAtfach n sketch plan or the proposed system. Also if the licensed Installer posesses a certified plot plan,
this plan should be submitted].
g�` . .--�� { t tfi+-�_, > `��y'y�.,S„ . -r ix "';t�s �� v+ '- • -. '� .� �+s' F F f z r r�" .lI F. - � r -ram?"'���a
-. `a3?!?�..>._s ..b+�r""✓J+.;i•.3 ..-.._....`��..A'e� WSJ^ -:u h _���?'w` �,�zy ,����i yY��i�`i�i���.r,*��� '�<'f�* _ylA .rv.�f�,K �px�t �L�' �. t
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PARCEL NO:_
Commonwealth of-Massachusetts
Grad
-Executive.Office of.Env(ronmmntal Affairs_ .. John e "
- -D.E.P. Title V Sep" Inspector
pp rtment Of-, - - P.G.pox 2-1-19
..Environmental Protection Teaticket, MA 02536
- (508).564-680
WMIam F.WId
Trudy CoXe
Breretary.EOEA
_ Danld B.Struhs s� -
- SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM M �fC��j/
--- - - - PART A '9R 649
\ CERTIFICATION 6'ta
_
_Propert Address: q� -Pvca vsen ( Address of Owner: '996 co
Y - 0�`�e
Date of Inspection: 3' V Colo (If different)
Name of Inspector:- .
Company Name, Address and Telephone Number:
CERTIFICATION STATEMENT
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_ Passes
_ Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
�Faiis -•
Inspector's Signature: V Date:
3 ae .
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design•, flow of i0,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to me system owner and cope: sen;.tu the buyer, if appiicable and the approving au:honty.
INSPECTION SUMMARY:
Check A, B, C, C
A] SYSTEM PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the'exisiing septic tank is replaced with a conforming septic tank'.as
approved by the Board of Health.
(zevased,8/15/95) <
One Winter Stra•t • Boston,Matisaehut•tb tt2108 FAX(d17)fll; 1j St9 • TaNpltona��(a/7) t• ; -5500 a
O�J�I Mr• ?�� 4 6t�'` iJ -b.A 1fi X �b ���
l�Punted on
.�
.� ��_ -�c�� %*�":'S `4 .'!�', �,.a .,.�. .- � t-,. ,�i,r�. ... ��.. •r�,[r-'�✓. ��' r..F3.:`U:�•9 a$'3�'��:�w��i�•..F.w�''-_',•�j x r'� .
t _
yti r
SUBSURFACE SEWAGE.DISPOSAL-SYSTEM INSPECTION FORM
PART A
_ CERTIFICATION (continued)
"Property dress:Gt" �o � iLC?1..�►�d
Owner. _ `�.0
Date of 1
nspedion:
1 at(_
B] SYSTEM CONDITIONALLY PASSES (continued)
Sewage backup or breakout or high static water level observed in the distribution box-is due to broken or obstructed
pipe(s) or-due to a broken, settled or uneven-distribution box The system will pass inspection if(with-approval of the
Board of Health): - -
_ broken pipe(s) are replaced _
obstruction is removed
distribution box is levelled or replaced
_ The system-required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Board.of Health): .. -
_ broken pipe(s) are replaced -
obstruction is removed
C].FURTHER EVALUATION 1S REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
I
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT: .
1 me >vstpm nd> a !.eUU( tdni anui wl; ib!,orpiion sy sten. and 6 Yr", 'r, i vv fcc; ;L a i j-r—
surface water supply.
The s\s!err has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
_—supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is
free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm.
DJ SYSTE
M
determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
-.for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
the failure.
Backup of sewage into facility or system component due to an overloaded or dogged 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
-- --
(revised 8/15/95) 2
------SUBSURFACE_SEWAGE DISPOSAL SYSTEM-INSPECTION FORM.
-- - — — _PART A
CERTIFICATION (continued) _
-Property Address:
Owner: �C'�
Date of Inspe ion:
D)SYSTEM FAILS(continued):
-Static liquid-level in the distribution box above outlet invert.due to an overloaded.or..clogged SAS or.cesspool.
- _ Liquid depth in cesspool is less than 6" below.invert or available volume is less than 1/2 day flow. —
_ Required pumping more than 4 times in the.last year NOT due to clogged or obstructed pipe(s)..
-Number of times pumped a -
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
The following criteria apply to large systems in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
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
—Me system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a
public water supply wells
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(ievised 8/15/95) 3
— SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B _
- - -- tHECKLIST
Property A : Q�. f�0(6"" 4ectd7�NW, _ -
Owner:
Date of-
Inspections-Check if the following have been done: -
_wnping information was requested of the owner, occupant, and Board of Health.
_Lt.p►rts of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period: Large volumes of water have not been introduced into the system recently or as part.of this inspection.
I .
built plans have been obtained and examined. Note if they are not available with N/A.
j _LJbe facility or dwelling was inspected for signs of sewage back-up.
"'rhe system does not receive non-sanitary or industrial waste flow
3 W site was inspected for signs of breakout.
--LA
ystem components, excluding the Soil Absorption System, have been located on the site.
.The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
! L-f{ie size and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive-methods.
_ The fa•i!:,,,, ,4 n i^;3^!c. if dlftP/PM frorn ownP-) were orovided with information on the proper maintenance of Sub-
Surface Disposal System.
'(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
. ----— - -- . -- - PART C
- — - - SYSTEM INFORMATION.
Property dress: T�i ��WQ� v( .• _ _ -
Owner: � -
Date of Inspection:
_-
_. - FLOW CONDITIONS _ -
RESIDENTIAL: -.
Design flow: d allons
Number of bedrooms'. -
Number of current-residents:
Garbage grinder (yes or no):-C�9
Laundry connected to system (yes or no): �5
Seasonal use (yes or no):-2D -
Water meter readings, if available:
Last date of occupan-'�-U-t, ��Q�S as
COMMERCIAUINDUSTRIAL: C V5
Type of establishment:
Design flow:__gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5.system: (yes or no)_
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RE RDS and source of inforSmati�,� -C ��
System pumped as part of inspection: (yes or no)c
If yes, vokrne pumped gallons
Reason for pumping:
TYPE 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)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
-eQIC
Sewage odors detected.when arriving at the site: (yes or no)
(revised^8/.15/95) 5
e
1• l 4� - i� 7M1 a T .'61 .' f. �.. yir�c( �- ..�._.....R.-Yam•..+'-�
�r w
S.S.....!••tc;.+, t." 'ire k:"<.r.. ].dt. i..'Y-3t• .. :'..,� i• . __. _..._�� �:...........-}....,,=.'�rv.•m.-.."�. •, �. .._ _...-.... -
= SUBSURFACE,SEWAGE.DISPOSAL SYSTEM INSPECTION FORM
---- ----- — — — PART C- -
_. SYSTEM INFORMATION (continued)
Property ress: 11�
r Owner-
' £C�am.
Date of Inspection: v`'JFill
SEPTIC TANK:—
(locate on site plan) -- _
Depth below grade:4.3
Material of construction: _Concrete _metal _FRP-_other(explain)
-Dimensions: t� ' " , (i� -
Sludge depth:_ -
Distance from top of sludge to bottom of outlet tee.or baffler
Scum thickness: ( - -
Distance from top of scum to top of outlet tee or baffle: -
Distance from bottom of scum to bottom of outlet tee or baffle:
Comments: -
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integri evidence of• e, etc.) 1 Cl
GREASE TRAP:_
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Scum tnil
Distance from top of scum to top of outlet tee or baffle:
Dicranro from botto.- l °ro—. t- hottom of outlet tee or baffle:
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidl of leakage, etc.)
(re'vised 8/!5/95) 6
w .
.. - . ...,. _. - ._ .. .. .-�.... .r. ..-. s.. ..A .aa.i u-'Yai"_.—...na:.1'i+P. v:r x� ...4.4a..•a._..�.,, „�!�las. .... T.Jill1L;, ... x).`
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued) -
- Property Address: -
Owner: �c-� A
Date of inspection: -
TIGHT OR HOLDING TANK:_Q\,C�
(locate.on site plan)_
Depth below grade:
Material of construction: _contrete _metal _FRP —other(explain)
Dimensions: -
Capacity: gallons -
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:—,.'�
(locate on site plan'
Depth of liquid level above outlet invert:
Comments:
tnote if levei no disLrwui-u , ryuai, e dance of so�id. ca:,)o.er, e�:dence of!eakage into or out of box, etc.! y �CY. nCl(1
PUMP CHAMBER:
(locate on site plan)
Pumps irrworking order:(yes or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
. 1
(revised 8/15/95)
c
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C- -
- SYSTEM INFORMATION (continued) _
Property Address:
Owner: - -.
Date of Ins ion: - "
p clko
SOIL ABSQRPTION SYSTEM (SAS):t---:
- -(locate on site-plan, if possible; excavation not required, but may be approximated by non-intrusive methods)
[foot determined-to be present, explain:
Type: . ` \
leaching pits., numberi��� YIAL (1 LQGClh PL�-- _
leaching.chambers'- number:_ _
leaching galleries, number: -
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments:-( ote condition of soil, ns of hydraulic failure, level of ponding, condition of vegetation,etc.)_.L-66 h
1Y� ).ark �r;t lit t .Ili r P
,g CESSPOOLS: �1j
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer.
Dimensions of cesspool:
materials of construction:
Indication of ground.:a:c-
inflow (cesspool must be pumped as part of inspection)
I
Comments: (note"Mndition of soil, signs of hydraulic failure, level of ponding; condition of vegetation, etc.)
PRIVY:
(locate on site Ian)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
i
r.
(revised 8/15/95) 8
•i ,
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C _
SYSTEM INFORMATION (continued)
-Property'A s�C
Owner: - � ,��
nsP Pr
Date of 1 eection:
SKETCH OF,SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks - -
locate all wells within 100'
P
o AA
kc
A ql)
o D
DEPTH TO GROUNDWATER
Depth to groundwater: G feet c
method of determination or approximation: U >Cr-3 2C\fl P �C-nc'( tj
(revised 8/15/95) 9
i
t E
ISO:.C.A T ION S E WA ......
V;!'•L L A 6 EE
777
I::NSTA LLER'S NAME i ADDRESS
0 c"2 C y :a
lUILDER OR OWNER
j
DATE PERMIT ISSUED
D41,1. COMPLIANCE ISSUED
,L£
Snvf/ Zqo y,76,,g
LOCATION SEWAGE PERMIT NO.
/, O-�-
V3LLAGE
I N S T A LLER'S NAME i ADDRESS
OU2 C�
'-��JGZ� icy,-j .„• ,�
UILDER OR OWNER
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED �y
I
.. �;
y� i
� �
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J
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�111' F
v � � f
� a.'�,.
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r
..
No.(v... Fps.�..�........................
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® F H ALTH
...............OF. ........ ......... . .....^ .... ....................................
Applira#ion for Bi_gpwi al Works Tnnitrnrtiun Vantit
Application is hereby made for a Permit to Construct V/) 'or Repair ( ) an Individual Sewage Disposal
073
Sys at s ---•--•... ...............•............... -•......................••••• ...
�� gcation/A s or LID, o.
.� .. 1.... :. .......................
Owner A dr
...................................... .......................
Installer Address
d Type of Building ze Lot............................Sq. fee
U Dwelling—No. of Bedrooms........... ..........................Expansion Attic (c✓) Garbage Grinder (1
Other—T e of Building ... No. of ersons....._yy
a YP g -•-•----•----------•--•-- P .�--•-••---•------- Showers (/) — Cafeteria
Otherfixtdres --••-••••-•••••--•----------------•---------•-----•-...••-•--•--•------•---•--••---•-•------------•---•-•----•--•---•--••--••-••------••-------•-•-•--
w Design Flow............. ................gallons per person per day. Total daily flow...........-.3.'�--a.................gallons.
WSeptic Tank—Liquid capacityA9?_0..gallons Length................ Width................ Diameter................ Depth................
x Disposal Trench I No..................... Width.................... Total Length------------- Total leaching area...__._._// sq. ft.
Seepage Pit No..........*f.�...__.. iameter..................... Depth below inlet..... Total leaching area_�____�?......sq. ft.
z Other Distribution box (�/) Dosing tank
a Percolation Test Resets Performed by......1n............. .. ......... .............................. Date...A-11-P_ ......_..
l Test Pit No. 1.--..:.0e1...minutes per inch Depth of Test Pit........1.1..... Depth to ground water..IV.& -E!r_q✓P
fT Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water.........................
P4 ------•-•---------. -- ........................................................-••-••......•---•••••............---....................
O Description of Soil
.......C.....�� .�4-°`" So�G.......___.
cx, ••••----•-••......•---------•-•••--•-� � ..... S3 _�a?�f�c Win' ---------- ----------------------------------------------------------------------------------
w ----••-•---------------•---•----------6------- ram-- s -1 . . ----- .
U Nature of Repairs or Alterations—Answer when appli able_____________________________________________•----------•----_-----.------------_-------_---•-.
..... ..........................................................................................................................•---........_......__...._................._............. /•
A eement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITL 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board o i lth.
Si ned.03�Nnvr a4 L/2 �? - .`-6"--- •------- ---..........................
� C134S� E � Date
Application Approved BY rea, ►�/1, c! *!! .--------- ....._' _.0 _ Q.'
Da te
Application Disapproved for the following reasons:.................... ......----------------------------------------------•------------•......---•-.......
--------•-•---------------------------------------------------------------•--------------•......----•-.........-•-••---•--------------•-----••-•--•---•----------------------------------------.....-••-
d. Date
Permit No. Issued l `
Date
No................_....._ FEs..............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...........................................OF........................................------........--•------------.....................
Appliratiun for Disposal Works Tonstrurfiun Vvrrmit
Application is hereby made for a.Permit to Construct ( • ) or Repair ( ) an Individual Sewage Disposal
System at:
................__---.......................................................................... ...---•..._...----•-•--.._.....•••...•••••-•-•......................•••••••••••.................•.
Location-Address or Lot No.
........................_........................................................................ .................._.............•......•••....._..................•••••••.......................--
Owner Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of!persons............................ Showers — Cafeteria
Other fixtures ............................ .
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid'capacity._..........gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—No. ___----_-------_-. Width...........:.........Total LengthN................... Total leaching area....................sq..ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'~ Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit...................... Depth to ground water......................It
Gi,, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a -----------------------------•---------------•----------•---•--•-----------------•-------•----------.........................................................
DDescription of Soil-------------------------------------•----•--••----...'-----------------------..../----•---••-••••---•••••-----•-••-••----....-••--••----•-•-•-•......-•--•-•---•-----
x
U -•--•••-----•••••-•--••-----••••••-•-••--••-•-•........--•--•••--••.....-•••-----•-•••---------•---••-.....----••-•-•----•--•-•----•--•---•••--•--••---•••-••---•••••••------•---•-•----••--•-•......••-
x ..-••••--------•-----•-•••........•-•-••-•--••..
-••-•-••-•••....••----------••---•••-•-•••-•--....._ ....---•---•--------•-•-----•-----------------------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
..------•---------------------------------------•---•-••-----------------------•••••--..............-••-•-•......-------•••-••-•••••-•--•••-•-•-•••••-••••--•-•--•-•••••••••-•--•••-•-•-............•-•-
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITIE S of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Signed........................•--------------------..................-•----••--••......•---• .......................
Date
ApplicationApproved By................................................................................................... `.....................................
Date
Application Disapproved for the following reasons::
.............................................................
� F r sL•
..............•---------..........-------•------••-•--•••-•---------•-•---- ' . •--•••...fir.....�4 ----........Date....*-•------
r
4
Permit No...-•----------••...............................-•••••... Issued• II
+ Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALT
T
..�..........OF...:,, ... ..... . ....................
Trrtif iratr of TutnpfiFaurr
THIS 7 0 C TIF That the Individual Sewage Disposal-System constructed (PI"or Repaired ( )
�..
by......_. .. ...::........................... Installer ...4'�' itary
...................................................
':V..
at• ... �' IQi�t!.'Ja -�
has been installed in accordance with the provisions of T j of The State Code as describe. in the
application for Disposal-Works ConstructionPermit No . .............. .... _.___....._..
THE ISSUANCE-OF THIS CERTIFICATE SHAL NOT BE CONSTR�IED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTIO SATISFACTORY. ✓✓
DATE--••-•-. ...._._�. \` J- Inspector �C�
. .........................•-•
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No. `e 7 ...... ../ ..I ...........0F..........� ............................................. �
FEE..-.. '� .
Dispose Word �(gonutra ion rrntit
Permissior,i5ohtreby granted... _ ,1. ,t _._ } °" .._�
to Cons ct J ) Repair ( ) an Indi+v]�al Sewage�ifs�posall System w '
at NO. ..----•7 ., `gyp� J•-•---7 1 J��°S=� "� 2! �° {1 f! •-
Street
as shown on the application for Disposal Works Construction rmit No..................... Datedl.._.,�> ./_�_..�.��..........
DATE------•�./.-•-/•7
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
TOWN OF BARNSTABLE
LOCATIGN i t\Uouj SEWAGE #
VILLAGE VUQN\S ASSESSOR'S MAP& LOTAU�O5
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 10 QC� t� 1
LEACHING FACILITY: (type) 4d0 -MU loe—k k S (size) LA ,
NO.OF BEDROOMS
BUILDER OR OWNER'
+EZflATE: ZZ COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table �'�2� Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility), _ 0, Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) i Feet
Furnished by ,�2 �•tm
e A
e
1
(MJ
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Ic °
i
q1k TOW
OF BARNSTABLE
LOCATION ` ci Dr SEWAGE #
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&'PHONE NO.
SEPTIC TANK CAPACITY q 0,j 1 6 'y\
LEACHING FACILITY: (type) l J (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of:Weiland and Leaching Facility(If any wetlands exist
within 300 feet Rif leaching fa ility) Feet
Furnished by
J
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/ C) d
' I IN
_ 7Sop
47A. � 36
p ;s
o'o� }203Et7L
�r
3•� GUNIKIS
No.2216 O is
��• 90�` C/STE�F,��i ,ems
NAt-
' •• LEGEND
EXISTING SPOT ELEVATION Ox0 CERTIFIED PLpT PLAN
;
EXISTING CONTOUR - - - 0 - - -_ �vT 7S 'Ap000w.Ale_jo "4o 0
FINISHED SPOT ELEVATION 10 A �N�s
' FINISHED CONTOUR
N
{ APPROVED : BOARD OF HEALTH �� ,�� 748 9jM.ASS
13.l A F
DATE AGENT S.
SCALE" / = 30 DATE
.. rL D RED GE ENGINEERING CO. ING� CLIENT PA cry .
I CERTIFY THAT THE PROPOSED
�EGISTERE[� ( REGISTEREDI JOB N0. '4 0 / / BUILDING SHOWN
ON THIS ;PL APl
CIVIL ; ' LAND' CONFORMS . TO THE ZONING; LAWS
.� ENGINEERS,' I,SURVEYORS� OR. BY / �� ...`�__ OF BARNST BL E , MASS.
3-Q NC' MAIN S" 712 MAIN 3T CH. BY __...
S0 : 7ARMOt; T-H, MASS. HYANNIS, Ma`» SHEET-�_ OF .. _ r/DAB E R G . LAND 'SURVEYOR'
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