HomeMy WebLinkAbout0115 BISHOPS TERRACE - Health 11 5 Bishops Terrace...
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COMMONWEALTH OF MASSACHUSETTS
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4 F EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
David B.Mason,R.S,Certified Title V Inspector,508-833-2177
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM .
PART A
CERTIFICATION
Property Address: 115 Bishops Terrace,Hyannis,MA tv
Owner's:Thompson
. Owner's Address:329 West Main Street,Hyannis,MA � � v:
p -�
Date of Inspection: May 28,2008
f..�
h_ Name of Inspector: (please print)David B.Mason
ompany Name: N.A.
Mailing Address: 4 Glacier Path
East Sandwich,MA 02537
elephone Number: 508-833-2177
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 15340 of Title 5(310 CMR 15.0001. The system:
X Passes
_Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signatu Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments: System as inspected is operational. Increase in occupancy may result in failure. Tank needs
maintenance pumping.The information as identified represents only the condition of the system on May 28,2008 at
7:30 AM.
****This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 115 Bishops Terrace,Hyannis,MA
Owner: Thompson
Date of Inspection:May 28,2008
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:
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 (THIS IS REQUIRED TO BE
COMPLETED)
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:
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
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Page 3 of 11
PART A
CERTIFICATION(continued)
Property Address: 115 Bishops Terrace,Hyannis,MA
Owner: Thompson
Date of Inspection: May 28,2008
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 wall 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:
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Titles 5 TnenAntinn Rnr r,11 ti,)nnn 3
Pagb 4 of 11
PART A
CERTIFICATION(continued)
Property Address: 115 Bishops Terrace,Hyannis,MA
Owner: Thompson
Date of Inspection:May 28,2008
D. System Failure Criteria applicable to all systems:
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 cesspool is less than 6"below invert or available volume is less than'h 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.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
_X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [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.]
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—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.
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Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 115 Bishops Terrace,Hyannis,MA
Owner: Thompson
Date of Inspection: May 28,2008
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)on the site 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(3)(b)]
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY AS
SESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
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Pagz 6 of 11
PART C
SYSTEM INFORMATION
Property Address: 115 Bishops Terrace,Hyannis,MA
Owner: Thompson
Date of Inspection: May 28,2008
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 (per assessors records)Number of bedrooms(actual):3 septic design
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): (330 gpd capacity)
Number of current residents:_0
Does residence have a garbage grinder(yes or no):NO(Not Allowed)
Is laundry on a separate sewage system (yes or no):NO [if yes separate inspection required]Per owner
Laundry system inspected(yes or no):NA
Seasonal use: (yes or no):NO
Water meter readings,if available(last 2 years usage(gpd)): 141,000 gpd for the past two years. (70,500gpd/year)
Sump pump(yes or no):No
Last date of occupancy: Approx. 6 months
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
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:
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: System pumped moments after inspection due to the need for maintenance pumping.
TYPE OF SYSTEM
X Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_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: 1991
Were sewage odors detected when arriving at the site(yes or no):no
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
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Page 7 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 115 Bishops Terrace,Hyannis,MA
Owner:Thompson
Date of Inspection:May 28,2008
BUILDING SEWER(locate on site plan)
Depth below grade: Approximate; 24 Inches
Materials of construction:_cast iron _X_40 PVC _other(explain): -
Distance from private water supply well or suction line:_NA
Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. No evident
leakage.
SEPTIC TANK:N.A.(locate on site plan)
Depth below grade: 12 inches
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: Typical 1000 gallon tank
Sludge depth: 11"
Distance from top of sludge to bottom of outlet tee or baffle: 14"
Scum thickness: 10 inches
Distance from top of scum to top of outlet tee or baffle: 15"
Distance from bottom of scum to bottom of outlet tee or baffle: 12.5"
How were dimensions determined: Actual measurements with tape and scour stick.
Condition of tank(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid
levels as related to outlet invert,evidence of leakage,etc.) PVC inlet tee in good condition,PVC outlet tee in good
condition,Effluent level with outlet pipe. In need of Maintenance Pumping. No evident structural issues. CI Cover
to grade on inlet. Riser on outlet which is 8"below grade.
GREASE TRAP: 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.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DJSPOSAL SYSTEM INSPECTION FORM
Title'; 7
Page 8 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 115 Bishops Terrace,Hyannis,MA
Owner:Thompson
Date of Inspection: May 28,2008
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:_NA_(if present must be opened)(locate on site plan)
Depth of liquid level even with outlet invert: liquid level even with outlet pipe
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.):No D-Box. There is a leach pit acting as a second septic tank.
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.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESS
MENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Title C Tnenartinn Fnrm Aii ;0n00 8
Page 9 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 115 Bishops Terrace,Hyannis,MA
Owner:Thompson
Date of Inspection:May 28,2008
SOIL ABSORPTION SYSTEM(SAS):—X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
X leaching pits,number 2.pits,One is acting as a septic tank and the 2°d is the leach pit.
_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,
etch 2nd leach pit is empty and clean,no signs of hydraulic failure or ponding,nor excessive vegetation growth.
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:_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.):
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Titles 5 Tnenartinn Rnr 9/1 V1000 9
Page 10 of 11
PART C
SYSTEM INFORMATION(continued)
Property Address: 115 Bishops Terrace,Hyannis,MA
Owner: Thompson
Date of Inspection:May 28,2008
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.
W
REAR
A B
DECK
1 0
O
Al 23'
131 22'
A2 47'
I
132 46'
F-1
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
Titles 5 Tncnvrtinn Rnr All siInnn 10
Page 11 of 11
SYSTEM INFORMATION(continued)
Property Address: 115 Bishops Terrace,Hyannis,MA
Owner:Thomspon
Date of Inspection: May 28,2008
SITE EXAM
Slope
Surface water
Check cellar (crawl space)
Shallow wells
Estimated depth to ground water_20 feet
Please indicate(check)all methods used to determine the high ground water elevation:
_X_Obtained from system design plans on record-If checked,date of design plan reviewed:
_X_Observed site(abutting property/observation hole within 150 feet of SAS)
_X_Checked with local Board of Health-explain: Recent Test Holes, Existing engineer records with BOH
_X_Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting
site topography. Groundwater Contour Map.
Title 5 TnQnP(`tlnn Fnrm All r%nnnn 11
O�THE Town of Barnstable
� 1p�
regulatory Services
Thomas F. Geiler, Director
saatasras[.E, :
MAM
ArE16.39.o,��a Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
REGARDING SEPTIC INSPECTIONS BY.PRIVATE CONTRACTORS
DISCLAIMER
This septic system inspection report was completed by a private inspector who is certified by
the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original or copy of the report;
this Division does not warranty the functionality of the septic system in the future nor does
this Division agree with any technical observations and interpretations contained within this
report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual number of
bedrooms approved at a particular property would be listed on the "Disposal Works
Construction.Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
QASEPTIC\Disclaimer Private Septic Inspections.DOC
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
0 .
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A RECEIVED
CERTIFICATION
Property Address: 115 Bishops Terrace AUG 1 '6 2002
Hyannis TOWN OF BARNSTABLE
Owner's Name: Alan Findley HEALTH DEPT.
Owner's Address:
Date of Inspection: 7/25/2002 st (9-1
Name of Inspector: (please print) Kevin J. Sullivan MAP 2rz,,
Company Name: Ready Rooter PARCH O IL
Mailing Address: P.O.Box 371
Sandwich,MA 02563 LOT
Telephone Number: (508)888-6055
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:
asses
Conditionally Passes
Needs Further Evaluation by the Local Authority
Fails
Inspector's Signature: Date: 9-6 1-0Z
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments
""This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address bow the system will perform in the future under the same or different
conditions of use.
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1,15 Bishops Terrace
Hyannis
Owner: Alan Findley
Date of Inspection: 7/25/2002
Inspection Summary:Check A,B,C,D or E /ALWAYS complete all of Section D
C. System Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the" onditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacementp 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 d'or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfil tion or tank failure is imminent.System will pass inspection ifthe
existing tank is replaced with a complying sep c tank as approved by the Board of Health.
*A metal septic tank will pass inspection if i s structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 year old is available.
ND explain:
Observation of sewage backup r break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broke 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 lox is leveled or replaced
ND explain:
The system requ' ed pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass inspection if( ' approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 115 Bishops Terrace
Hyannis
Owner: Alan Findley
Date of Inspection: 7/25/2002
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require finther evaluat/vegetated
r f Health in order to determine if the system
is failing to protect public health,safety or the enviro
1. System will pass unless Board of Health detcordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner whic public health,safety and the environment:
_Cesspool or privy is within 50 feet of a su
—Cesspool or privy is within 50 feet of a boated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public ater Supplier,if any)determines that the
system is functioning in a manner that protects the public he lth,safety and environment:
_The system has a septic tank and soil absorption sys em(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water sup y.
_The system has a septic tank and SAS and the S S is within a Zone 1 of a public water supply.
_The system has a septic tank and SAS and th SAS is within 50 feet of a private water supply well.
_The system has a septic tank and SAS and a SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to ermine distance
"This system passes if the well water an is,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indi es that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate itrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the alysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 115 Bishops Terrace
Hyannis
Owner: Alan Findley
Date of Inspection: 7/25/2002
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all inspections:
Yes No
_ Jackup 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 and overloaded or clogged SAS or
cesspool
_ _e%kiquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
_ _�/ equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumpers
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.
_ fAny portion of a cesspool or privy is within a Zone 1 of a public well.
— _jZ Any portion of a cesspool or privy is 50 feet of a private water supply well.
-,Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
(Yes/No)The system fails. I have determined that one or more of the above 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 mast e a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either`Ryes"or"no"to each of a following:
(The following criteria apply to large systems in ddition to the criteria above)
yes no
the system is within 400 feet of a s ce drinking water supply
_the system is within 200 feet of butary to a surface drinking water supply
the system is located in a ni sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone H of a public water well
If you have answered"yes"to any qu 'on in Section E the system is considered a significant threat,or answered
"yes"in Section D above the large tem has failed.The owner or operator of any large system considered a
significant threat under Section E failed under Section D shall upgrade the system in accordance with 310 CMR
15.304.The system owner shoal contact the appropriate regional office of the Department.
i
Page 5 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 115 Bishops Terrace
Hyannis
Owner: Alan Findley
Date of Inspection: 7/25/2002
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?
_ZHave 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 bates or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
Was the facility owner(and occupants if different than owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 115 Bishops Terrace
Hyannis
Owner: Alan Findley
Date of Inspection: 7/25/2002
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms):3 3® G'e-o—
Number of current residents: _3
Does residence have a garbage grinder(yes or no):A-4p
Is laundry on a separate sewage system(yes or no):.s/a[if yes separate inspection required]
Laundry system inspected(yes or no):
Seasonal use:(yes or no): ipa
Water meter readings,if available(last 2 years usage(gpd)): oTcx7=7= y497 G-v-x- a c;,o l= 0 7 6•,t.-e
Sump Pump(yes or no): 1&::)
Last date of occupancy: r�5 �
COMME RCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.20 gpd
Basis of design flow(seatsipersons/s etc.):
Grease trap present(yes or no):
Industrial waste holding tank prese t(yes or no):
Non-sanitary waste discharged to a Title 5 system(yes or no):_
Water meter readings,if availabl .
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the ins ion(yes or no):A o6
If yes,volume pumped: gallons--How was quanttypumped determined?
Reason for pumping:
TYPrF OF SYSTEM
_peptic tankr4isb4butieu-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:
L
�.'C cry wm{�(i�►'L �w VNR� t%. iA�
w
Were sewage odors detected when arriving at the site(yes or no): &,,V
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 115 Bishops Terrace
Hyannis
Owner: Alan Findley
Date of Inspeetio-w 7/25/2002
BUILDING SEWER(locate on site plan)
Depth below grade: t 5
Materials of construction:mast iron�40 PVC_other(explain):
Distance from private water supply well or suction line: g-js!xes°
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK
: (locate on site plan)
Depth below grade: I cD •�
Material of construction: ✓concrete,metal—fiberglass_polyethylene
other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of
certificate)
Dimensions:
Sludge depth:
Distance from the top of sludge to bottom of outlet tee or baffle: ;
Scum thickness: --s "
Distance from top of scum to top of outlet tee or baffle: a "
Distance from bottom of scum to bottom of outlet tee or baffle: / R"
How were dimensions determined: �,:.y.0 W - p, ��
Comments(on pumping recommendations,inlet and outlet tee or bafl3e condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
GREASE TRAP: (locate on site plan)
Depth below grade:_
Material of construction:_concrete metal_fi/asspolyethylene other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee baffle:
Distance from bottom of scum to bottom of tlet tee or baffle:
Date of last pumping:
Comments(on pumping recommends i ns,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of eakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 115 Bishops Terrace
Hyannis
Owner: Alan Findley
Date of Inspection: 7/25/2002
TIGHT or HOLDING TANK: (tank must be pumped t time of inspection)(loc ate on site plan)
Depth below grade:
Material of construction:_concrete metal—fiber ass_polyethylene_other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working ord (yes or no):
Date of last pumping:
Comments(condition of alarm and float tches,etc.):
DISTRIBUTION BOX: /ibution
st be opened)(locate on site plan)
Depth of liquid level above outlComments(not if box is level ao outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
PUMP CHAMBER: (lo )
Pumps in working order(yes or./
Alarms in working order(yes o
Comments(note condition of pundition of pumps and appurtenances,etc.):
• Page 9 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 115 Bishops Terrace
Hyannis
Owner: Alan Findley
Date of Inspection: 7/25/2002
SOIL ABSORPTION SYSTEM(SAS): -Z
ocate on site plan,excavation not required)
If SAS not located explain why:
Type
ching pits,number:
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/alternative system Typetname of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
+'C- k i---- r rw .es c
CESSPOOLS: (cesspool must be pu ped as part of inspection)(iocate on site plan)
Number and configuration:
Depth—top of liquid to inlet invert: f
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater in ow(yes or no):
Comments(note condition 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 f soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
• Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 115 Bishops Terrace
Hyannis
Owner: Alan Findley
Date of Inspection: 7/25/2002
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system includingties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
O
a
1
O
01 CID
- � �� � O �-
` Page 11 of 11
OFFICIAL INSPECTION FORM,NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 115 Bishops Terrace
Hyannis
Owner: Alan Findley
Date of Inspection: 7/25/2002
SITE EXAM
Slope
Surface water
Check cellar a�
Shallow wells
Estimated depth to ground waterC1 5" feet
Please indicate(check)all methods used to determine the high ground water elevation:
`AZ'6btained from system design plans on record—If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with the 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:
TOWN OF BARNSTABLE
LOCATION lid IJIS��S ���r ° SEWAGE # `I l 6eq
VILLAGE 'I , ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. 16US- '
SEPTIC TANK CAPACITY 1,060
LEACHING FACILITY:(type) 1 (size) x
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER 1 A,Ini`}�(�•i�
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
�-.
� ��
v y�
.�',
"' 0'
® � � . �
��
��
6�
NO.,,...e-----lflrl Fss...3. 7_-
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Apphration for Uiiipasal Warks Tonstruetinn Frrutit
Application is hereby made for a Permit to Construct ( ) or Repair (Individual Sewage Disposal
System at:
...........14"3--- %. r—�r�sa _ - ':c !( ----------- ------------------- - i' -- ...............................................
-Ad ress or Lot No.
............... f ..........................................................
Owner
ss
_ e
Insta ler 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
dOther fixtures ------------------------------------------------------.••••----•----------.-•-•---------- .............................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................
xDisposal Trench—No_____________________ Width.................... Total Length_______r___._________ Total leaching area--- ---------------sq. ft.
Seepage Pit No-------r------------- Diameter._. _________ Depth below inlet.....C?t_________ 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........................
P4 ------
•--------------------------------
•----------------------------------------------------------
------
•----------------
------------------------
-......
ODescription of Soil-•---------------.......................................................................................................................................................
x
U •--••-••-•••--•--•••••----•-••---•--•••-••--•----•-----•------•-------•------------------•-•-•••----•-••----------•--•-•-----•-•-----•-•---••----------••----•-------------•-------......------------•--
x ---••------•-----------------------------•---•--•--...••••-•---••-•••-•••-------------•-•-••-•--•••-----•--------•---•--------------------•---•••••-•--••••.-.-------------------•----:----------------
U Nature
�yo-f—Repairs or Alterations—Answer when
when applicable.___l__.�__.A�d)o_____ _y 5� ___h ib' _ � _�_______..
_D__�--�_--°'-=--•--- t _=_•-. Ji--3`!.�_F :.�C- ....a�- S-'iE._w------------------_--•-• --•------
---------------•-----•-•---•--•------...--•---
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 health.Signed ----- ... .------.3 -------
Application Approved By .............. -�SD Date
Application Disapproved for the?Oloinglw reafon.r- -----------------------------------------------------------------------------------.................................................
----------------------------------------------------------- ...................................--------- ---------------------------------...--------------------..........................----- .......................................
Date
PermitNo. ----- { ,��------------------------------- Issued ---------------------------......................._........------
Date
THE COMMONWEALTH-OF MASSACHUSETTS r s
BOARD -OF- HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Tvustrnrtw' n Permit
Application is hereby made for a Permit to Construct ( ) or Repair ( G,) arIndividual Sewage Disposal
System at:
............t -I.::.
......................rG . :frn/Q , _ �::�
Location-Address or Lot No.
----•-------- I �"e N J t....r.... ... A^^ 11#, .... .
.. ......... ................
Addres
�.... Owner--..
_
...c n .R...::c,u............. .......... .. ...1 x...� ���vt�,.<<c ....------
-...� - ,
Installer Address
d Type of Building Size Lot............................Sq. feet
U Dwelling No. of Bedrooms............................................Ex anion Attic� g— p ( ) Garbage Grinder ( ) -
p, Other—Type of Building ............:............... No. of persons............................ Showers ( ) — Cafeteria ( )�
Other fixtures ...
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
xSeptic Tank—Liquid capacity............gallons ,Length................ Width................ Diameter................ Depth................
Disposal Trench No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No........I--- ........ Diameter.._. ---- Depth below inlet.....Ce(........ Total leaching area..................sq. ft.
Z Other Distribution box ( ) ' Dosing tank ( ) -
aPercolation Test Results Performed by........ ••••••-•1-••-•--••••-•-•••-•••••••••-••••--•--•-••.............. Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit*................... Depth to ground water........................
f%4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
p .....--------------------------------------------------------------------•----------------•---------------------------------*,-"--••------------
......
0 Description of Soil.................
U •--•-----•---------•--------•---------------------------------•----------.....-------------------------•----------------------......-----------....------------•-------------...--•••-•-•..... •...--
----------------------------------------------------------------------------------------------------------------------------------------------------•-------------------------------------......-r...
U Nature of Repairs or Alterations—Answer when applicable........... .
� 1"r._f�. �.1.�...__..
............... ,-P........ �-,� �� .���_�r_��+c� b�'A��-•---------------------------- ....----
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. t
-- '7 - =r,Signed ..... `
...... r: Date ^-4 � �... ..
Application Approved By ........ �' _ .�.-.� ......................---------.................................... ......�--
-------- --
�.J Date
Application Disapproved for the fo lowing reasons: ---------------------------------------------------------------------------------------------- ----------------------------
-----------------------------------------...........................------- ---- ---- -----------------------------------------------:..--- ---................................................ --...-----------D ...................
Permit No. -.../�. .............. Issued ................................ ate.:.... ...
Date - -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C&ertifirate of Clomplianc.e
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired
b - F_..4-- 1 ..!7--�� .-�1t 14 c...:............................................................................................. ......
y-----.-...----............................ .+/' Installer---...................-..at ---------..................... ---------? � :•�..�C"_' a-�r.lrr_ `'�? -- ?,'c;` - .. k :..w.( d. ...---...---....---...
has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. ..........;C�/...-.. .., '........ dated ........... ..................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.. ..J ...-1.1................................................................... Inspecto -......._............
............ ...................... ----_------
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Disposal Narks %Tunsir ion "Vrrmit
/'• - t/\. /\ t to �r of ..... G:: '.t7.. ::.�......................................................
Permission is hereby granted............L....:.�_.,:�-..„,...�..,_.,...�...•;_ . � ,.
to Construct ( ) or Repair ( �) an Individual Sewage'Disposal System
�_ r .: v.....: .:1: :a -• ....-at No................! .............--
: Street' t
as shown on the application for Disposal Works Construction Permit No.,_?Z...�. ... Dated..,.. ../
o .....................................................
Board of Health N
DATE................... ........................
FORM 36508 HOBBS&WARREN.INC..PUBLISHERS
TOWN OF BARNSTABLE
ql
LOCATION �i IJ►5� ' ��� SEWAGE 1
VILLAGE e�" ASSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO. U64,A'
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) _(size) K .
NO. OF BEDROOMS
53 _PRIVATE WELL OR PUBLIC WATER
1
BUILDER OR OWNER
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
i
No. ---------- Fuim....2.....C)CJ, ..
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OR HEALTH
. ------- OF..........�?. 'dS/.... ✓G
�Applira$ivu for 13ispnsal 19orks .( oustrurtiun ramif
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
- . .............. .........._....... .............................................
Loca on-Address or Lot No
..... �lil �l........ .�?/ ���-� .. .......................... •.......T 1.4...-...... ....,,....1f�1 ✓ y..................
``/
Owner Address
lX./ ................................... ......................................................................... ....................
Installer Address
Type of Building Size Lot....... �P..D .Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( .) Garbage Grinder ( )
'4 Other—Type of Building ....... No. of persons............................ Showers — Cafeteria
Q' Other fixt es -------------------------------- . d
W Design Flow..-........_5...........................gallons per person per day. Total daily flow-__------ ._._ ._.._.:.__._.__.__.__gallons.
P4 Septic Tank—Liquid capacity/O&.gallons Length................ Width................ Diameter---------------- Depth................
xDisposal Trench—No. ................._. T>dth____...._.._..._..._ Total Length......_............. Total leaching area....................sq. ft.
Seepage Pit No/ ._ .. lDi etfl"r.................... Depth below inlet.................... Total leaching area..34.1-/....sq. ft.
Z Other Distribution boxy( ) Dosing tank ( )
Percolation Test Results Performed bY.......................................................................... Date........................................
Test Pit No. 1__----_-__-__-minutes per inch Depth of Test Pit-__---------------- Depth to ground water......................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water---_-_---_--_-_-__--_--.
P4 --•---------••• ............................ -------------------------__------------------•-----_-..------......_.------•-----_------
ODescription of Soil............. � ------ .�' v L---------------------------------------------------------------------------------------------------..
x
W
----------------•-----•-----------------•------------•-•--•-•-----•-•••.......----••-••-•---•--••-----...-••--•--------------------•------•-----------••••••..........................................
UNature of Repairs or Alterations—Answer when applicable................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss ed by board f th,
Signed. . ... ••--- ..----...... Z:�Z'._7 .
l� v Dale
Application Approved By..................
Date
Application Disapproved for M following reasons------------------------------------------------------------------------------------------------- --------------
-------------------------•---------------------------------------------------..._.......--------------------------------------------------------------- ---•------•---•--•••------•--••---------------
Date
Permit No.......1.V_/._:.....-••............................. Issued.. .-/ -
No.----
-2-./........... ...............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
................ ......
... ................................................
Application is hereby.made'for-a Permit to Construct or Repair an Individual Sewage Disposal
-System at:
... ................ ................................ ...............................................
4-a 7-- '6� -V
....................................................
Local'o ,Address
tt. ..
or Lot No. V
........
....7............................... .......... 2!L......... ....... .................................
owner Address
................................................................................................. ..................................................................................................
Installer Address
Type of Building Size Lot............................Sq. feet
U
Dwelling—No. of Bedrooms........ ...............................Expansion Attic Garbage Grinder
Other-.Type of-Building ---------- ........... ..... No. of persons............................ Showers Cafeteria
Otherfixtures .....................................................................................................
'Design Flow._........... ...................gallons per person per day. Total daily flow--____-_--..-
j�2 .....___._._..___:.gallons.
14 Septic Tank—Liquid capacity,ef.�'00_gallons Length................ Width......_......_._ Diameter_.......__..._.. Depth................
Disposal Trench—No.._ .. Width.................... Total Length..._............._.. Total leaching area._...._ sq. f t.
> age Pit I/ bi Seep g..... ardet r.................... Depth below.inlet._.................. Total leaching area...34Av.-.-sq. ft.
Z Other Distribution box--( Dosing tank
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................rninutes per inch Depth of Test Pit-------------------- Depth to ground water._.-____-__-____-__.__-.
f� Test Pit No. 2................minutes per inch Depth of Test Pit.____-_-_______._.__ Depth to ground water-----------------------
..................................................................................��
...........................................................................
0 Description of Soil--............ ...... --------- ...................................................................
-----------------------
U ....................................................................... ..............................:��........................../Y_-4-1111111---
............................ ---------------.................................................... -------------------------------- .....I........................................................
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 Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
-operation until a Certificate of Compliance has been issped by the board f 4,eMth.
SignedF� .... . ............. ................................
_ JAatV
Application Approved BY-------------= j &
................. ...... ........
Z17-------------------------------------------------------------------------------- 2
Application Disapproved for th6f6llowing reasons:................................................................................................................
......................................................................................I-------------------------- ----------------- ..............................................................
Date
7
Permit No.------ ........................................ Issued... .
-
-----
. ..... ...... .................
THE COMMONWEALTH OF MASSACHUSETTS
"
BOARD OF HEALTH
.......................OF......
........................
............
01prtifirate 'af Tomplinurr
THIS IS TO CERTIFY, That the Individual-Sewage Disposal System constructed or Repaired
by............ .............. ...................................................................................................................
Installer
at...._X-t"/-—--------4,Z/----------------n -------------- - -- --------------------------------*-------------------------------------------------6v
has been installed in accorda .. e provisionis 6�
, e o The State Sanitary Code as described in the
application for Disposal Works Construction Permit No....--- ---------------------------- dated...,_-----_gpt......!7---�k.....................
;. XGUAkAN'
THE ISSUANCE OF THIS CERTIFICATE SHALL` T BE CONSTRUED AS / " i
. 6 TEIE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE.................. i
Inspector0 1 . .
. .1el 4, ............
7
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTHi
.................
OF......Nod ........................................
................... 7 7 FEE,,
.................
Permission is hereby,granted-----.i ........ ................ ......................................................
to Construct or Repair' an Individual Sewage Disposal System
_;�...........................................at 140... ........... ...7n.;
6, i��........�ry 7 7�9 ..........................
Street
�f;2................
as shown on the application for Disposal Works Construction Permit No_,...,........... Dated---
... .... . --....-
Board of Health
DATE---_--------- ................. -------------------------
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS