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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
H 273 Arrowhead Drive
Property Address '
Patricia Maarques
Owner Owner's Name r
information is H annis Ma. 02601 09/28/2017 t
required for every y
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information 51#, a
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael T Bisienere
use the return Name of Inspector
key.
Cape Septic Inspections
Q Company Name
624 Old Barnstable Road
Company Address
Mashpee Ma. 02649
City/Town State Zip Code
508-280-3356 S13938
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
10/01/2017
nspector'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
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.
t5ins.doc•rev.6/16• Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17Uc
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maarques
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/28/2017
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I 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:
This 3 bedroom home has a H-10 1000 gallon septic tank and a H-10 D-Box feeding a leaching pit. At
the time of the inspection there was appx. 4 feet of ponding water in the leaching pit. At the time of
the inspection this system met the requirements of The Town of Barnstable to pass Title 5.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y 0 N ❑ ND (Explain below):
.A
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title .5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maarques
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/28/2017
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
I
I
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):-
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
r 15.303(1)(b)that the system is not functioning in a manner which will protect public health;
safety and the environment:
Cesspool or privy is within 50 feet of a surface water
❑' Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
• t
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maarques
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/28/2017
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
*"This system passes if the well water analysis, performed at a DEP certified laboratory, for 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.
3. Other:
- r
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No" to each of the following for all inspections:
Yes No
El ® 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 'h day flow
t5ins.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Y
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maarques
Owner Owner's Name
information is
required for every Hyannis Ma. 02601 09/28/2017
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ - ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is,less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory, for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ ®' The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the.
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate.,
regional office of the Department.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17.
,i
Commonwealth of Massachusetts
v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maarques
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/28/2017
page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
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 CM 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3 -
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): < 330 GPD
l5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maarques
Owner Owner's Name
information is Hyannis Ma. 02601 09/28/2017
required for every
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 3
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
In 2016 23,000 gallons were used and in 2016 28,000 gallons were used
Sump pump? ❑ Yes ® No
Last date of occupancy: occupied
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maarques
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/28/2017
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool i
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy.of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,.•'' 273 Arrowhead Drive
Property Address
Patricia Maargues
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/28/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 47"feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
36"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: Standard H-10 1000 gallon septic
tank
Sludge depth:
1"
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maarques
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/28/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
36"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
5"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Sludge Judge
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
I would recommend the new owner put the tank on a maint. plan with a local septic pumping co.The
Barnstable Health Dept. has a list of local septic pumping co.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maarques
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/28/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 111 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maarques
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/28/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
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 H-10 D-Box had no visible signs of leakage or evidence of past hydraulic failure.
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.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
l5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maarques
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/28/2017
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number:
One
❑ 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.):
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
i
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 -
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maargues
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/28/2017
_
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
i
i
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maarques
Owner Owner's Name
information is Hyannis Ma. 02601 09/28/2017
required for every
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
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
Re rm,'4- ez�
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
I
I
TOWN OF BARNSTABLE
LOCATION a 7,3 �,�I1GYc���c� �/ SEWAGE
VILLAGE c/Ann ASSESSOR'S MAP 6, LOTO/�"49j/
INSTALLER'S NAME& PHONE NO. ;E/2 M,aComhe•- 50h � c
• SEPTIC TANK CAPACITY /OOU
LEACHING FACILITY-(type) f7/7�' (size) 1000
NO.OF BEDROOMS / PRIVATE WELL OR PUBLIC WATER
BIWA ER OR OWNER
DATE PERMIT ISSUED:-
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No !�
i
3/ / \\\ �
1. �s� �r /.ya
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maargues
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/28/2017
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 15 plus feet
feet
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:
I augered a hole to 15 feet.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
4
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
273 Arrowhead Drive
Property Address
Patricia Maargues
Owner Owner's Name
information is required for every Hyannis Ma. 02601 09/28/2017
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
n
JVT6
t5iris.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d
DEPARTMENT OF ENVIRONMENTAL PROTECTION
V�v
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION � ]_ 9
Property Address: #273 Arrowhead Drive RECEIVED
Hyannis,MA
Owner's Name: Mauricio&Ana Lima NOV 1
Owner's Address: 156 Arrowhead Drive 3 2002
Hyannis,MA 02601 TOWN OF BARNSTABLE
Date of Inspection: 11/9/02 HEALTH DEPT.
Name of Inspector: (please print) Mr.Carmen E.Shay
Company Name: Shav Environmental Services,Inc. MP
Mailing Address: 34 Thatchers Lane PARCEL :,
East Falmouth,MA 02536
Telephone Number: (508)-548-0796 LOT
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:
XX Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Autho
Fails AR
r
Inspector's Signature: 9�1, Date: 11/9/02 o y
• eFdlTlf��
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow o'
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.
Notes and Comments
2' effective depth remaining in leach pit.
****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 6i15/2000 page I
f
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: #273 Arrowhead Drive
Hyannis,MA
Owner: Mauricio and Ana Lima
Date of Inspection: 11/9/02
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
XX 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:
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:
T tlo'f lncnurtinn l nrm ail v�nnn 2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: #273 Arrowhead Drive
Hyannis,MA
Owner: Mauricio and Ana Lima
Date of Inspection: 11/9/02
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria 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:
T;.io c I--t;— P— Aii 4;11nnn 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: #273 Arrowhead Drive
Hyannis,MA
Owner: Mauricio and Ana Lima
Date of Inspection: 11/9/02
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ XX Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
XX Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
XX Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
_ XX Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
XX Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
_ XX Any portion of the SAS,cesspool or privy is below high ground water elevation.
XX Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
XX Any portion of a cesspool or privy is within a Zone 1 of a public well.
_ XX Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ XX 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 forma
NO (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.
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.
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)
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—I WPA)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.
4
Page 5 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: #273 Arrowhead Drive
Hyannis,MA
Owner: Mauricio and Ana Lima
Date of Inspection: 11/9/02
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
XX Pumping information was provided by the owner,occupant,or Board of Health
XX Were any of the system components pumped out in the previous two weeks?
XX _ Has the system received normal flows in the previous two week period?
XX Have large volumes of water been introduced to the system recently or as part of this inspection?
XX _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
XX _ Was the facility or dwelling inspected for signs of sewage back up?
XX _ Was the site inspected for signs of break out?
XX _ Were all system components,excluding the SAS, located on site?
XX _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of t he baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
XX _ 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
XX _ Existing information. For example, a plan at the Board of Health.
XX _ 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 Title C 1--ti— V—411 cnnnn
I
Page 6 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: #273 Arrowhead Drive
Hyannis,MA
Owner: Mauricio and Ana Lima
Date of Inspection: 11/9/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: Unk.
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No (if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use: (yes or no): Yes
Water meter readings, if available(last 2 years usage(gpd)):
Sump pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sqft,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: None on File
Was system pumped as part of the inspection(yes or no):
If yes, volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
XX 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:
1995-per Board of Health&Owner Records
Were sewage odors detected when arriving at the site(yes or no): No
T;tlo f 1--ti— 97— 411 rnnnn 6
Page 7 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #273 Arrowhead Drive
Hyannis, MA
Owner: Mauricio and Ana Lima
Date of Inspection: 11/9/02
BUILDING SEWER(locate on site plan)
Depth below grade: 24"
Materials of construction: XX cast iron XX 40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints, venting,evidence of leakage,etc.):
SEPTIC TANK: XX (locate on site plan)
Depth below grade: 9"
Material of construction: XX 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)
Dimensions: 5' deep x 5'wide by 8' long (1000 gallon)
Sludge depth: 4. 75'
Distance from top of sludge to bottom of outlet tee or baffle: 3.00'
Scum thickness: 4"
Distance from top of scum to top of outlet tee or baffle: 4
Distance from bottom of scum to bottom of outlet tee or baffle: 12
How were dimensions determined: Measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Structural integrity of tank was ok-No evidence of cracks leaks or water infiltration/exfiltration. 4" PVC Tee present and
in good condition Outlet Tee also in good condition. Liquid level equal with outlet invert.
GREASE TRAP: _(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(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
T do 4/1 cnnnn 7
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
SYSTEM INFORMATION(continued)
Property Address: #273 Arrowhead Drive
Hyannis, MA
Owner: Mauricio and Ana Lima
Date of Inspection: 11/9/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: Present (if present must be opened)(locate on site plan)
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.): One outlet to leaching Pit. D-Box in good condition.
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,etch
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: #273 Arrowhead Drive
Hyannis, MA
Owner: Mauricio and Ana Lima
Date of Inspection: 11/9/02
SOIL ABSORPTION SYSTEM(SAS): XX (locate on site plan,excavation not required)
If SAS not located explain why:
Type
XX leaching pits, number: 1 —6' deep by 6' diam. precaste
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.): No evidence of hydraulic failure, ponding damp soil or stressed vegetation. Probed stone with no
evidence of hydraulic failure. Excavated cover.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow(yes or 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:
Dimensions:
Depth of solids:
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
Y T41a c 1.,�..A,.6— G,...., AlI cnnnn 9
Page 10 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #273 Arrowhead Drive
Hyannis,MA
Owner: Mauricio and Ana Lima
Date of Inspection: 11/9/02
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
D-Box
0 Leach Pit
0 Septic Tank
(1000 Gal.)
0
Deck
B A
3 Br
House Swing Ties:
A-Tank Out—32'
B-Tank Out—35'
A—D-Box—35'
B—D-Box—40'
A—Leach Pit —318'
Waker B—Leach Pit—55'
Line
Arrowhead Drive
T:fio c i.,�..o *c,.� F..,., �ii�nnnn 10
Page 1 I of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: #273 Arrowhead Drive
Hyannis,MA
Owner: Mauricio and Ana Lima
Date of Inspection: 11/9/02
SITE EXAM
Slope
Surface water - None
Check cellar -Yes
Shallow wells—None
Estimated depth to ground water 14 feet below grade.
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:
XX 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)
XX Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Checked with Ouadrangle of USGS Map
Per Barnstable GIS:
Elev. of Ground=50 Feet
Elev. Of Groundwater=25 Feet
Elev.Of Bottom of Leach Trench=40 Feet
Therefore: 40—25 = 15 feet separation between Bottom of Leach Trench and Groundwater.
Groundwater Adjustment using Index Well AIW230 : 7.7 feet
Adjusted Groundwater Separation= 15'—7.7' =7.3 feet
(Refer to attached work sheet)
Grade=Elev. 50 feet
Leach Pit
D-Box
Septic.Tank
Bottom of Leach Trench=Elev.40 feet
Adj.Groundwater=Elev. 32:7
T;tla G Incnortinn Gnrm 411 ci�nnn 11
r
I
i
I
I Permit Number: Date:
i
Completed by:
HIGH GROUNDWATER LEVEL COMPUTATION
Site Location: OC 3 A��s� •� 1 )Cel� F-�VtG \� Lot No.
Owner: NfWzlC.10 UlNhR Address:
M IF—
Contractor- Address: ?)nX (Oa�- �Q�tS101� r MA ao1s3c�
Notes.
i
STEP I Measure depth to water table
to nearest 1/10 h. .............................................................................. Date IL � J5
mont / ov
f
STEP 2 Using Water-Level Range Zone
and Index Well Map locate
site and determine:
q►w
OA Appropriate index well.................... '
i
O Water-level range zone ..................................................... i
I
t
STEP 7 Using monthly report "Current
i
Water Resources Conditions"
determine current depth to
water level for index well ........................... I�nthOy�r I
l
nso
I
i
STEP 4 Using Table of Water-level Adjustments
for index well (STEP 2A),current depth
to water level for index well (STEP 3),
and water-level zone (STEP 28)
determine water-level adjustment ..........................................................................................
• I
STEP 5 Estimate depth to high water
i
by subtracting the water•
level adjustment (STEP 4)
i from measured depth to water
level at site (STEP 1) '
I
f
t
COMMONWEALTH OF MASSACTUSETTS /
x x EXECUTIVE OFFICE OF ENVIRONMENTAL AEI:FAIRS _
DEPARTMENT Or ENVIRONMENTAL PROP&CTION" r1'
o-
rAVE9
350 MAIN STREET .•�' NQ I
WEST YARMOUTH,MA 3 4 POOO
508-775-2900 0SI.0;
Carl= �t' "k
TITLE 5.
OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM �*
PART A
CERTIFICATION
Property Address: 273 ARROWHEAD DRIVE
HYANNIS,MA 02601
Owner's Name: JULIE PAOLINI
Owner's Address: 273 ARROWHEAD DRIVE
I-IYANNIS,MA 02601
Dale of inspection NOVEMBER 15,2000
Name of Inspector:(please print) JAMES D.SEARS
Company Name: A&B Canco
Mailing Address: 350'Main Street
West Yannoufli,MA 02673
Telephone Number: 508-775-2800
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(31.0
CMR 15.000). The system:
X Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails �
Inspector's Signature: Z¢B_01 Date: 11-17-00
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 fie system is a shared system or has a
design flow of 10,000 gpd or greater,the inspector and lie,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 tot
he buyer, if applicable,and the approving authority.
Notes and Continents
THREE(3) BEDROOM HOUSE,THREE(3) OCCUPANTS. USED FOR DAYCARE AS
WELL WITH FIVE OR MORE PART-TIME.
.****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 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 273 ARROWHEAD DRIVE
HYANNIS,MA 02601
Owner: PAOLINI,RJLIE
Date of Inspection: NOVEMBER 15,2000
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes: X
_ 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: N/A
_ 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 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:
_ 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:
Title 5 Inspection Form 6/15/2000 2
Page 3 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 273 ARROWHEAD DRIVE
HYANNIS,MA 02601
Owner: PAOLINI,JULIE
Date of Inspection: NOVENIBER 15,2000
C. Further Evaluation is Required by the Board of Health: N/A
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is
failing to protect public health,safety,or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,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 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 conform
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:
Title 5 Inspection Form 6/15/2000 3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(CONTINUED)
Property Address: 273 ARROWHEAD DRIVE
HYANNIS,MA 02601
Owner: PAOLINI,JUL1E
Date of Inspection: NOVEMBER 15,2000
D. System Failure Criteria applicable to all systems: N/A
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded
or clogged SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
X Liquid depth in pit is less than 6"below invert or available volume is less than%2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped
X Any portion of the SAS,cesspool or privy is below high ground water elevation
N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a
surface water supply
N/A Any portion of a cesspool or privy is within a Zone 1 of a public well
N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well
N/A 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 cotiform 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 or less than 5 ppm,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.)
NO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as
described in 310 CUR 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: N/A
To be considered a large system the system must service a facility with a design flow of 10,000 gpd to
15,000 gpd.
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)
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 11 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 is 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.
Title 5 Inspection Form 6/15/2000 4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 273 ARROWHEAD DRIVE
HYANNIS,MA 02601
Owner: PAOLIrII,JULIE
Date of Inspection: NOVEMBER 15,2000
Check if the following have been done. You must indicate"yes"or"no"as to each of the following
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X Has the system received normal flows in the previous two week period?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X Was the facility or dwelling inspected for signs of sewage back up?
X Was the site inspected for signs of break out?
X Were all system components,excluding the SAS,located on site?
X 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
X 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)has been determined based on:
Yes No
X Existing information. For example,a plan at the Board of Health.
X 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(3xb)]
Title 5 Inspection Form 6/15/2000 5
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 273 ARROWHEAD DRIVE
HYANNIS,MA 02601
Owner: PAOLINI,JULIE
Date of Inspection: NOVEMBER 15,2000
FLOW CONDITIONS
RESIDENTIAL
Number of Bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms: 330
Number of current residents: 3 AND 5 DAYCARE
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): YES
Seasonal use(yes or no): NO
Water meter readings,if available(last 2 years usage(gpd)): 1999 1006 CU.FT.2000 1061 CU.FT.
Sump pump(yes or no) NO
Last date of occupancy: N/A
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203):
Basis of design flow(seats/persons/sgft,etc.):
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/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: N/A
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or noxif 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 copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
1995 PERMIT#95-469
Were sewage odors detected when arriving at the site(yes or no): NO
Title 5 Inspection Form 6/15/2000 6
i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 273 ARROWHEAD DRIVE
HYANNIS,MA 02601
Owner: PAOLINI,JULIE
Date of Inspection: NOVEMBER 15,2000
BUILDING SEWER(locate on site plan): N/A
Depth below grade:
Materials of construction: Cast iron _ 40 PVC _ other(explain)
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK(locate onsite plan): X
Depth below grade: 30"
Material of construction: X 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)
Dimensions: 1,000 GALLON PRE CAST
Sludge depth: 2"
Distance from top of sludge to the bottom of outlet tee or baffle: 27"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 19"
How were dimensions determined: ASBUILT AND TAPE
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
MAIN TANK AT WORKING LEVEL,OUTLET TEE,OUTLET COVER 30"BELOW GRADE.INLET COVER
8"BELOW GRADE.
GREASE TRAP(located on site plan) N/A
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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as
related to outlet invert,evidence of leakage,etc.):
Title 5 Inspection Form 6/15/2000 7
i
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS _
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 273 ARROWHEAD DRIVE
HYANNIS,MA 02601
Owner: PAOLINI,JULIE
Date of Inspection: NOVEMBER 15,2000
TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass polyethylene other(explain)
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no)
Alarm level: Alarm in working order(yes or no):
Date of last pumping
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: X (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: 0
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 Y BELOW GRADE.ONE LINE IN,ONE LINE OUT.
PUMP CHAMBER: N/A (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.):
Tide 5 Inspection Form 6/15/2000 8
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 273 ARROWHEAD DRIVE
HYANNIS,MA 02601
Owner: PAOLINI,JULIE
Date of Inspection: NOVEMBER 15,2000
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X 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.)
ONE(1)1,000 GALLON PRE CAST PTT. PIT 4'6"BELOW GRADE.PTT COVER 18"BELOW GRADE, 18"
WATER IN PTT WITH NO HIGH STAIN LINE.
CESSPOOLS: N/A (cesspool must be pumped as part of inspectionxlocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool
Materials of construction:
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation etc.):
PRIVY: N/A (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.)
Title 5 Inspection Form 6/15/2000 9
Page 9 of l I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 273 ARI20WI-IEAD DRIVE
RYANNIS,MA 02601
Owner: PAOLINI,JULIE
Date of Inspection: NOVEMBER 15,2000
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locale all wells within 100 feet. Locate where public water supply enters the building.
-J
30
0 0
55, �
0
Title 5 Inspection Form 6/1.5/2000 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: 273 ARROWHEAD DRIVE
HYANNIS,MA 02601
Owner: PAOLM,JULIE
Date of Inspection: NOVEMBER 15,2000
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater 25.7 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:
Observation site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation
X Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
USGS WELL DATA OCTOBER 2000. WELL AIW 230 AT 25.7.
USGS WELL 25.7',BOTTOM OF LEACHING 10' 6"BELOW GRADE.
Title 5 Inspection Form 6/15/2000 11
r TOWN OF BARNSTABLE
LOCATION a 7,� i9P7ZC vkeaj br SEWAGE
VILLAGEQ&nI7 / 5 ASSESSOR'S MAP & LOT���'"d�/
INSTALLER'S NAME & PHONE NO. fOh "dJC-
SEPTIC TANK CAPACITY /DOO
LEACHING FACILITY:(type) f I (s'ze)�bDO...
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BLM&DER OR OWNER.
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No !� ,
7
u
w, ' u
FEBI..Q 04........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
n TOWN OF BARNSTABLE
f' Applirativit for Bi-tip t ial lftrlw Towitrudion rumit
Application is hereby made for a Permit to Construct ( ) or Repair)CM an Individual Sewage Disposal
System at:
..................... 73 Arrowhead,Drive„Hyannis,.Mass,
............... ----•-......•••••-••--••--------------------.....---............-----•-••---
Location-Address or Lot No.
..................... i lups........................................................... ....I.............................................................................................
Owner Address
WJ.P.M__acomber.-Jr-•........................................ -----------------..........-------------•-----•-------•--•----•--••---•----------..........--•----
� Installer Address
Type of Building Size Lot............................Sq. feet
DwellingX-- No. of Bedrooms----------a...............................Expansion Attic ( ) Garbage Grinder ( )
pa-t Other—Type of Building ............................ No. of persons-----..-----..-------------- Showers ( ) — Cafeteria
a Other fixtures ---•-••-•-----•-•-•----------- - -
W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons.
WSeptic Tank—Liquid capacitv------------gallons Length.................Width................ Diameter................ Depth................
x Disposal Trench— No. .................... Width.................... Total Length.........---........ Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. -
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by----------••--•........--•------•-••••••-----=••-------------------------- Date.........................................
Test Pit No. I................minutes per inch Depth of Test Pit.------------.-----. Depth to ground water....---------..--.-.....
li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.............--.........
1:4 --•-•-•------•----------------------------------------•--•-•---------•----......•----••......................................................................
0 Description of Soil........................................................................................................................................................................
�C Sand & Gravel
v .................••--.....---...•--•- ------------------------•••-••-••-••-•••••••---------....--•---•-•-•-------------•---•--•----------••-•••••••-•---------•--------------------••-••---------•••••-
W
U Nature of Repairs or Alterations—Answer when applicable............Omit Cesspool Install ---100-----gallon
- - - - ----
------------------rank__1_-distribution,bnox„1-1,OOQ Q J-�.Qxa..1�ching--pit-.........................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental 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 ... �-.,. ......�'�'J.. `�......L . 3/15/95
:......
Dare
Application,Approved By ....:.... ............... .. .. ......... .................... ... ......r........................................... . b�....:.��-�,1 -�
Dace
Application Disapproved for,the following reasons: ........................................................................................................................................
................................................................................................................................................................................................................ ........................................
Permit No. .�.... C: ,........... Issued ........7,_WZ�.....:.�i�1�y=
Dare
Fims.�... 0.00
HEALTH-� 6 ' THE
BOARD *OFF F MASSACHUSETTS
TOWN OF BARNSTABLE
Appliratiori for Diopoottl Worth Towitrurtiori ramit
~ Application is hereby made for a Permit to Construct ( ) or RepairX(= an Individual Sewage Disposal
System at:
1273 Arrowhead Drive Hyann s,Mass-._
•------------------------------------••-•----------------------..........................._----•-
Location-Address or Lot No.
Phillips
......................_.......................................................................... -•••••--•-•-•--•---••--•--•-••••••-•..........••----•-••••-•••••-••-.........-•-•-•......-----•---
Owner - Address
FW ...J.P.Macomber Jr.
S" Installer Address
UType of Building Size Lot............................Sq. feet
DwellingX-- No. of Bedrooms.__-_•_-__3-------------------------------Expansion Attic ( ) Garbage Grinder ( )
Pk Other—Type of Building ____________________________ No. of persons._____________________.._.__ Showers ( ) — Cafeteria ( )
a' Other fixtures ................................
W Design Flow............................................gallons per person per day.- Total daily flow--------------_t----------------------------gallons.
WSeptic Tank—Liquid'capacity___._____---gallons Length________________ Width---------------- Diameter................ Depth................
x Disposal Trench—No_ ____________________ Width..................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No...................... Diameter.................... Depth below inlet-------------------- Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by-----------:.............................................................. Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.......................
44 Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................
-•---------•--••--------•--•--
0 Description of Soil......................................•-•---•-•---------••----•-••-----•----••-=--------•-•-----------•----------_:...................--•--•........_...............----
x Sand & Gravel
V ................•---------•..................._.....------•-------•-•-•-•--------••.......•••-•------••----.._................---••---...--•-----•------...----...........••--•-•----•--•••-•-••-•-•••--.
W ------------------------------------------------------------- ---...................................................................
x Onut cesspool_ Install 1-1000 gallon
V Nature of Repairs or Alterations—Answer when applicable........................ .. .. . ...._.................._...._.. .
tank 1-distribution bnox 1-1000 gallon leaching pit.•----------- -
Agreement:
The undersigned. agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Environmental 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 ...... - / 3/15/95
:...-...... . r7.. ..................... .................. .. .............................:.....
Dare
Application.Approved By ......................... :............. .........0............. ... .........�2�
'Date
Application Disapproved for the following reasonf: ........................................................................................................................................
........................................................................................................................... ................................................................................. ................................. ..
Permit No. . ......
ce
.....G".,/��.........., ........... Issued .................................................U�...
Dare
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
('IPrtifi a e of (ILInmpliance
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or RepairedY(XM
by ................. . :
)
J.P.Macomber Jr. ......................................................................................................
.....................................................................................
Installer
273 Arrowhead Drive Hyannis.mass.............................................................................�.
at ....................................... ........................................_ ....................................................
has been installed in accordance with the provisions of TITI 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit Nol'E ..�—�i�y ..... dated :....�4',l '�.f�JC
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE A AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.............. ..'"./ ............ .... ...... Inspect r.1............................ ........ ...:........ .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE $ 30.00
// 1' FEE........................
�totDSI orko curio#rr#iori VPr2ritt
Permission is hereby granted...J.P.Macomber `7rA----------------------------------------•-----------------------------.-.--.----..-..---------.----.
to Constr ( or RRe air ) an Individual Sewage Disposal System
at No...... 3 Aowhead Drive Hyannis.
------------------------------------------------------------------------------------
Stree
as shown on the application for Disposal Works Construction Permi �__ Dated_ //_........_�_.�5...
DATE-- ? ------------------------
Board of Health
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS