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HomeMy WebLinkAbout0113 BRIARWOOD AVENUE - Health 113 .Briarwood Avenue Hvannis p A = 288 079001 o ° ° e ° e v Commonwealth of Massachusetts ,ip Title 5 Official Inspection Form <II Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 113 Briarwood Ave Property Address r C.s Bener Real Estate LLC + ? Owner Owner's Name information is ✓required for every Hyannis MA 02601 02-26-2020 ' 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. Inspector Information on the computer, use only the tab Michael T Bisienere key to move your Name of Inspector cursor-do not Cape Septic Inspections use the return Company Name key. 52 Rivers End Road Co � Company Address Teaticket Ma. 02536 �I City/Town State Zip Code 508-280-3356 S13938 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails y Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board'-- of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 113 Briarwood Ave Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 page. Citylrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: this 3 bedroom home has an H-10 1000 gallon septic tank and an H-10 D-Box feeding a precast leaching pit with stone. At the time of the inspection the leaching pit had appx. 3 feet of avaible room. And no visible failure was found. The septic tank was pumped after the inspection. Note the septic system is in the front yard and none of the system is in the driveway lay out. It appears that cars have been parked in the front yard. The septic system is not rated to be driven on. At the time of the inspection no damage to the system was visible. 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 113 Briarwood Ave Property Address Bener Real Estate LLC Owner Owner's Name information is Hyannis MA 02601 02-26-2020 required for every —Y page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 113 Briarwood Ave u- Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 - page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ 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 b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ` Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ` 113 Briarwood Ave Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply 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 2000 gpd- 10,000 gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 113 Briarwood Ave V� Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 — page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] l5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 113 Briarwood Ave Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. 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 lug GPD Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ .Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: In 2019-6200 cubic feet were used and in 2018-7900 cubic feet was used Sump pump? ❑ Yes ® No Last date of occupancy: occupiedDate r t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i, Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 113 Briarwood Ave V Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Barros septic pumping. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons gallons How was quantity pumped determined? drivers est. Reason for pumping: Maint. l5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 113 rBriarwood Ave Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known) and source of information: Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 32"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: Town water feet Comments (on condition of joints, venting, evidence of leakage, etc.): water was flushed and it came freely. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 113 Briarwood Ave Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 24"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 5„ Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 31" Scum thickness 5" Distance from top of scum to top of outlet tee or baffle 1" Distance from bottom of scum to bottom of outlet tee or baffle 15" 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 recommend the new owner put the septic tank on a maint. plan with a local septic pumping co. based on the future use of the home. At the time of inspection the liquid level was at working level and the tee's were in place.The septic tank was pumped after the inspection. t5insp.doc-rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form lie Subsurface Sewage Disposal System Form -Not for Voluntary Assessments L.- 113 Briarwood Ave Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. 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 t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts _ ,p Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 113 Briarwood Ave Property Address Bener Real Estate LLC Owner Owner's Name information is Hyannis MA 02601 02-26-2020 required for every y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): 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.): At the time of the inspection the liquid level was at working level and there were no visible signs of leakage or solids carryover. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments • � 113 Briarwood Ave Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No" Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 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: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 113 Briarwood Ave 1 r- Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): At the time of the inspection there were appx. 3 feet of availible space and no visible failure criteria was found. 12. 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 ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Flo Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 113 Briarwood Ave Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts �n Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 u � 113 Briarwood Ave Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 TOWN OF BARNSTABLE LOCATION tl.I�;4g-Akftl SEWAGE N VILLAGE_ ASSESSOR'S MAP&LOTAJT J INSTALLER'S NAME&PHONE NO. > SEPTIC TANK CAPACITY LEACHING FACILrrY:(type) �`�l�/I1yC� (size) 6j�de NO.OF BEDROOMS r � BUILDER OR OWNER 11dI1 �q��J PERMITDATE: j�` COMPLIANCE DATE: eA--;% 7 Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and aching Facility If any wetlands exist within 300 f/ ��f Ong fa i�it Feet Furnished y / r r/ �a o j 113 ,BR/ARWOOO. Commonwealth of Massachusetts Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u— 113 Briarwood Ave Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 14 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 at a lower elevation and I shot it with a transit to show 4 feet of seperation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 113 Briarwood Ave Property Address Bener Real Estate LLC Owner Owner's Name information is required for every Hyannis MA 02601 02-26-2020 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 U. DATE:11 /1 2/01 PROPERTY ADDRESS: 113_Briarwood Ave ---------- Hyannis *,Mass. -" 02601 ------------------------ On the above date, I inspected the septic system at the above address. This system consists of the following: 1 . 1 -1000 gallon septic tank. 2. 1 -Distribution box. . 3 . 1 -1000 gallon leaching pit. V M V Based on my Inspection, I certify the following conditions: 4 . This is a title five septic system. ( 78 Code ) 5. The septic system is in proper working order_ at the present time. 6. -The leaching pit is dry at the present time.The stain line on the pit is 2 ' SIGNATURE: Name:_J_P_ Macomber Jr .______ Company: Jose_ph_P. Macomber—& Son , Inc . RECEIVE® Address:. Box 66 DEC 0 7 2001 -------------------- TOWN OF BARNSTABLE Centerville , Ma . 02632-0066 HEALTH DEPT. Phone:— 508-775-3338 -------------------- a THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tan ks-Cesspools-Leachfields Pumped & Installed Town Sewer Connections P.O. Box 66 Centerville, MA 02632-0066 775-3338 775-6412 • .�---\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 1 1 3 Briarwood Ave Hyannis. _,Mass. Owner's Name: Rudolf Ciani Owner's Address: 1 50_Sewall Ave Win h Date of Inspection: 11 / 12/01 Name of Inspector: (please print) J.P. Macomber Jr. Company Name:Joseph P. Macomber & Son Inc Mailing Address: P.O_ Box 66 spnt-pruille Ma 02632 Telephone Number: 508-775-3338 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: —uVPasses Conditionally Passes Needs Further Evaluation by the Local Approving Authoriry l' & ail rI Inspector's Signature: Date: ��'l `d 4 The system inspector shall s mit 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 'J"•'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 I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 1 1 3 Briarwood Ave Hyannis,Mass. Owner: Rudolf Ciani Date of Inspection: 1 1 1 2 01 Inspectio ummary: 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:The septic system is in' proper working order at the present time B. System Conditionally Passes: 106 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: . 2 Page 3 of I I OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 1 3 Briarwood Ave Hyannis,Mass. Owner: Rudolf Ciani Date of Inspection: 1 1 /1 2/A 1 C. Further Evaluation is Required by the Board of Health: ,&6_ 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 f rtctioning in a manner that protects the public health,safety and environment: The system has a septic tank and soil absorption system SAS and the rP y (SAS) SAS is within 100 feet of a surfce water supply or tributary to a surface water supply. It/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 b t 50 feet or more froth a private water supply well". Method used to determine distance "This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of 11 x OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 1 1 3 Briarwood Ave yannis,Mass. Owner: Rudolf Ciani Date of Inspection:) 1 12 01 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No/ _ y 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 PX& _ _ Liquid depth-in el is less than 6"below invert or available volume is less than 'h day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped 0 _ Any portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. y portion of a cesspool or privy is within a Zone I of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. JAny 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 triavered. A copy of the analysis must be attached to this form.] --OP(Yes/No),., ��-� ,ave determined that one or more of the above failure criteria exist as describ`ed`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 j 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. 4 Page 5 of 1 I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 1 1 3 Briarwood Ave Hyannis,Mass. Owner: Rudolf Ciani Date of Inspection: 11 12 01 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes /�Pumping _ information was provided by the owner, occupant, or Board of Health X/Has re any of the system components pumped out in the previous two weeks? the s stem received normal flows in the revious two weekperiod y p . 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? —Z_ Was the site inspected for signs of break out? _ Were all system components,e�eluding the SAS, located on site? _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees, material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: Yes no Existing information. For example,a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(3)(b)) 5 Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 1 1 3 Briarwood Ave. Hyannis,Mass. Owner: Rudolf Ciani Date of Inspection: 1 1 1 2 01 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):IX f = �� Number of current residents:0 Does residence have a garbage grinder(yes or no): .01v Is laundry on a separate sewage system(ye or no): 40 [if yes separate inspection required] Laundry system inspected�(yes or no): Seasonal use: (yes or no): 76S Water meter readings, if available(last 2 years usage(gpd)): �kd Sump pump(yes or no): kb Last date of occupancy:d4��A) COMMERCIALdNDUSTR.IAL Type of establishment: Design flow(based on 310 CMR 15.203):_ AA gpd Basis of design flow(seats/persons/sgR,etc.): Grease trap present(yes or no): i(/lQ 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: /9 Last date of occupancy/use: OTHER(describe): I$ GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):_ If yes, volume pumped: d gallons-- How was quantity pumped determined? �( Reason for pumping: TYP;y OF SYSTEM Septic tank,distribution box, soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no)(if yes,attach previous inspection records, if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from sy�Fn owner) I Tight tank L Attach a copy of the DEP approval Other(describe): A oximate aze of al components, date installed(if known)and source of information: zud& Were sewage odors detected when arriving at the site(yes or no):., , 6 Page 7 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 1 1 3 Briarwood Ave Hyannis,Mass. Owner: Rudolf Ciani Date of Inspection: 1 1 1 2 01 BUILDING SEWER(locate on site plan) �r Depth below grade: Materials of construction: cast iron /40 PVC of er(explain): Distance from private water supply well or suction line. Id Comments(on condition of joints, venting, evidence of leakage, etc.): Joints appear tight.No evidence of of leakage. The system is vented through the house vents. SEPTIC TANK: Zlocate on site plan) Depth below grade: Material of construction: concreteAP' metal.0 fiberglass4Lpolyethylene Nrt other(explain) If tank is metal list age:V4 Is age confirmed by a Certificate of Compliance(yes or no):A/0 (attach a copy of certificate) Dimensions: Sludge depth: Distance from top sludge to bottom of outlet tee or baff]e:,7 p_ Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bottom of outlet tee or baffle: �,� How were dimensions determined: WeAk/ml l Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pump the septic tank every 2-3 years_ Tnl"Pt P. outl Pt t-PPS are in place tank i s ct-ritrtiira11 y Isound and shows; no o;rideny-A of leakage.Liquid level at the outlet invert is 51 inches. GREASE TRAPK"(locate on site plan) Depth below grade:4 Material of construction:40 concrete kmetaLE1i¢fiberglass4// olyethyleneA other (explain): 10f Dimensions: Scum thickness: Allf Distance from top of scum to top of outlet tee or baffle: .elA Distance from bottom of scum to bottom of outlet tee or baffle: 61,# Date of last pumping: d0d Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease trap is not present 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 1 3 Briarwood Ave . Hyannis,Mass. Owner: Rudol f Ci ani Date of Inspection: 1 1 11 2 01 TIGHT or HOLDING TANK6-4-)L(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: A,�� Material of construction:AW concrete vA metal I&JO fiberglass�/4 polyethylene y�_other(explain): ,�JA Dimensions. Capacity: �-/ gallons Design Flow: UAq gallons/day - J' ' Alarm present(yes or no): _" Alarm level:�„4 Alarm in working order(yes or no): , Date of last pumping: _lit? Comments(condition of alarm and float switches, etc.): Tight or holding tanks are no presen DISTRIBUTION BOX: 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.): Distribution box has one lateral.No evidence of solids carry over. No evidence of leakage into or out or the b000x PUMP CHAMBER4)2+L(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.): Pump chamber is not present 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 1 3 Briarwood Ave Hyannis,Mass. Owner: Rudolf Ciani Date of Inspection: 11 12 01 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 1 -1000 gallon.„precast leachingoit_Packed iin stone_ 6 ' X10 ' / If SAS not located explain why: ; Loca-ted; Sao page ten C Type /�� / J leaching pits, number: 1 d� leaching chambers,number: 0 i� leaching galleries,number: 6 7� leaching trenches,number, length: D /1 leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: ng,TC;t;' Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): ditim fine no;No signs of hydraulic failure or paga nog'HYng'Vi �', are dry- V _A an is normal -Waste water stain . 23" up from the bottom of the pit or 53" below the invet pipe. The �� sit i u $ pumped as ai-NiYn(c spool must a pumped as� o tpection)(locate on site plan) Number and configuration: 0 Depth—top of liquid to inlet invert: ,{) Depth of solids layer: Depth of scum laver: 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.): Cesspools are not present. PRIVYQ,�(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.): Privy is nest- present- 9 Page 10 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 1 1 3 Briarwood Ave Hyannis,Mass. Owner:Rudolf Ciani Date of Inspection: 1 1 /1 2/01 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. 10 0 113 ,BR/ARW O0D, 10 ' -T xTS'' al�� •s ,A -: '4`:�.7r. n • r , :tom L0 'CAT10'fr SE-WA ,GE PERMtT VILLAGE I N S T A LLER'S NfME i ' ADDRESS R UILDERL OR OWNER FII. .,.i.I.I. .::.•.� �.:� ..'r�. ��,¢¢:i}, '.�.� DATE . PERMI.T' : :ISSNE' D D:A.TE C0MP1I. N C E 1SS`UEDlfc : 3 r Page 11 of 1 1 r OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:1 13 Briarwood Ave Hyannis,mass. Owner:Rudolf Ciani Date of Inspection: 11 /12/01 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: Observed site(abutting property/observation hole within 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: Ground water above sea level USGS; 2-000-1 Plate #2 USGS;Oberservation well data. Top of Ground I Leaching Pit /� . ;eet Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method Therefore, the vertical separation distance between the bottom of the leaching pit and the adjusted groundwater table is feet. 11 .+•Rnrv.-rt�Tr-T-:rnranr'nlswrsT'ir�nrsrrr:•fr+trnrrtr►'mrni mr+t7J Tr�7ranr�T bl Barnstae TOWN OF WARD OF HEALTH SUIISURFACF SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D •- CERTIFICATION �.t.- �T••.- e-r.tt�-.�rrm T'1w rt.•rn rwrresYrrT'nn:r-t't-1vrw11 arr'Ar`A+RRAr/R1���7 r�nn ..-.rP*-•r-�. •�.-TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 113 Briarwood Ave Hyannis,Mass. ' ASSESSORS MAP , BLOCK AND PARCEL # 288-079-001 OWNER' s NAME Rudolf Ciatli PART D - CERTIFICATION NAME OF INSPECTOR Joseph P. Macomber Jr. COMPANY NAME Joseph P. Macomber & S.Qrn Inc COMPANY ADDRESS P.O. Box 66 Centerville Ma 02632 Street Town or City Stat• t I P COMPANY TELEPHONE (508 ) 775 3338 FAX ( 508 ) 790 -1578 A CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal, system at this address and that the information reported is true , accurate , and omplete as of the time of .inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Chec one : s System: PASSED 4--- The inspection «hick I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 , 303 , Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con o'eted has found that the system fails to protect the public health and the environment in accordance with Title 6 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection orm . r , 41 Inspector Signature ' Date .a:r 0( ne copy of this c .ification must be provided to the OWNER, the BUYER where applicable ) and the 130ARD OF HEALTH. * If the inspection FAILED, the owner or operator shall upgrade • the system within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CHR 16 . 305 . partd .doc TOWN OF BARNSTABLE L(?CATION SEWAGE # UII.L GEC AVC0Jl..J/f.. ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) ��� -tZ�� (size) NO. OF BEDROOMS B j � I UII.DER OR OWN/ER PERMITDATE: G �'r COMPLIANCE DATE: Separation Distance Between.the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge'of Wetland and aching Facility If any wetlands exist within 300 f t 1 �ngfa Feet Furnished y g (13 U % / Q � N, eAS -� \' t . N a i LO,GATION SEWAGE PERMIT M lmis i VILLAGE Y INSTA LLER'S RI, ME & ADDRESS f U I L D E R OR OWNER DATE PERMIT ISSUEDloollo , DATE COMPLIANCE ISSUED ���/ � A No. .-� .. Fps..... .............. THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF H ALTH - .--.°....0 F......:.............................. ApplirFa#inn for .Uiiplas al Works C9nnitrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 61 ..................� '�ltc o'................................Avl..c------------------------ ----- - Location-.A d s or Lot No. ----...---_, ......... s.�_l ........................... ---------............---....---------------- ......------ nr� Address a c� .1 �..................................................•- Installer Address Q Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms____________________ ___Expansion Attic ( ) Garbage Grinder ( ) 04 Other—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) a' Other fixtures ________________________________ WDesign Flow.............................................gallons per person per day. Total daily flow------------_7..?_G................gallons. 04 W Septic Tank—Liquid capacity,/(�allons Length................ Width................ Diameter________________ Depth................ x Disposal Trench—No_ ____________________ Width.................... Total Length.................... Total leaching area_ __C....sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Resu s Performed by.......................................................................... Date........................................ aTest Pit No. 1. .._. __minutes per inch Depth of Test Pit____________________ Depth to ground water........................ f� Test Pit No. ____. ___minutes per inch Depth of Test Pit____________________ Depth to ground water........................ �' --------------------------------------------4------------... .........._............................... Description of Soil-/-•-••-••----•-- ---------------•-----------------•------------- x C— -••----•-••--••••-•...._••-•----•••---•-•-----•-- •-••••••-••------------••••••-•--•-•-•..............• �� _._ VNature 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 TITLL 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu e bo ealth. •-•--• -•--•---...._ ---Sig /�a ApplicationApproved By.................................................................................................. Date Application Disaroved for the following reasons:....... .. _ _:_.� : ------------•-•--•---.._..--•••--••-=--------------------------------•--------------...---•-•----------_.__.._.._....--•---------•-----------------------------------•---------•----••-•-•••-------•--- Date Permit No...•-•..�!4.'4_A_S......................... Issued_......Vbi-j.U_/ &.......................... Date NO..`...�... .' •••• FE&.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF H ALTH ..----- ! C ..........OF_...........................(...... Apptiration for Disposal Works Tonotrurtion ramit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: / ' G© Z �J� '.�Ft ....................................0 Z�l Ic...................../.. f_ Location-Address / or Lot No. .... L.. l-�-r' - .��.r-__.�� 5..:._!C,, -------------------- --- ............................................. .........------ �r r Address Installer Address d Type of Building Size Lot.................... .....Sq. feet Dwelling—No. of Bedrooms................... ...........Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) P4 Other fixtures ---------------------------------•---------__----- ^� g _..gallons per person per day. Total daily flow_____________1_ __' ________________gallons.__ W Design Flow_--•----•-------------------------------- - 2. WSeptic Tank—Liquid capacity/j6".gallons Length................ Width................ Diameter__.---_._-_--___ De th............._.. 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 Res is Performed by......................................................................... Date........................................ aTest Pit No. 1 I . _minutes per inch Depth of Test Pit.................... Depth to ground water_.____________-_--___--. (i Test Pit No. mutes per inch Depth of Test Pit____________________ Depth to ground water........................ O17< -•••---•------•--------•----•-•-••-••••-•••-••--••-•••' -------------------------------------------•------ -•-•-._...........-- Description of Soil-------------------- -•----.:..._...--_...---- -------•-- -r'�" . ----•------------ ---- -_...._ . '_Cl.. ...... ......V •----- -----------•............. ..................•--••• 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 TITLE: . 5 of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issu he board7ealth. g Date Application Approved By.................................. Date Application Disapproved for the following reasons:___.___z_•�:.. �:._:_=_. :? ').... .�. ......................••--...••••--------.....` ......•-...----••-------•-••••----•--••--.....-••••-•-••-•---•-••--•-•••••-•-•-•-•••-••......------•....••••-uti•---•--•_-----------------_...._ Date .......n:r.. Permit No. - r -... Issued•--•-b Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF NEALTH ....� ...........3.........OF................. ....... .......................................... , � ��,,, T of iratr of faontp ianrr THIS IS TO WTIFY That the ndividual ewage jo isposal -'stem constructed ( ) or Repaired ( ) by-------- � ,.. __.��'................ ---••---•----••-••--------•--•...........................•---------•---•----•-- Installer at......................................................................-•---•-•.._..•---•--•••--•••--...----•-•-•-•-••-•-•-•--•-•••-•--•••••••-•-••••••-••-•-••----•••-••----•-•-......--••••......•-- has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No.__.`� L -• -_.................. dated................................................ THE-ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM 4IL�L FUNCTION SATISF CTO Ys DATE.......................:........... /.! Inspector .....------------•---------------••-•------------•----••---•-----•-_-•••- k THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ ...........OF.......................... NO... / FEE........................ Disposal n ko otr � ' it r it c ' �-' Permission is hereby granted ..-•---•••--_�.. ---- `� [1 to Construct (?�) or,Repair ( ) an Individual Sewage JD p�sal y�tem at No. P�� >=- ,d,3. i,np%s v....�J��_....---- Z" . .. -i`--..s.--------- Street as shown on the application for Disposal Works Construction Permit,.No.S .+?......... Dated.......................................... -•--._..........: :.... -•-•----------••---•-•-••. ---•-•------------------------------------------- ^y pg y t! Board of Health DATE--r'r �" -= .......................................... FORM 1255'.-A.-'M. SULKIN, INC., BOSTON - q0 - - - / .. y dr:z3 of i 'Z7,�_. \ ��' potTj s -.99 2:0AWS Se`PT,< � ✓ �t -r-Esr 9�o q K Z' IS U /00 rt000 NLk 14 r p9,d h SE rah C!< s • o b OF L°T Z (4,z_ N g A. ORSE v, ° C�Z:, Z�, LA/ A �Ne10951�0 U x Z 5 90 N f o G/STD a��`�� N F Mc al S/ONALE �•c, ►S5h3I3 oc LEGEND ROBERT , Z BRUCE EX"TING TOT ELEVATION 0%0 � LDRE CERTIFIED PLOT. PLAN EXINTIMIS CONTOUR -- 0 -- 01 t 3MED. SPOT ELEVATION ( , .�o� Ln-T z swovEr<- v l�NQ® CONTOUR O yo sup' ti/�/s Po 7 910 ' The, location of any existing uunnde�rgro_, r Overage, IN _ : .o.r other .utilities. shown on this plan .is -ap2rox-. � �mat.e_only 'as : determined from records, and/or. verbal a�nformation. The contractor is responsible for the verification of the.existing locations in the field. SCALE� / �_ 10 � DATE N�c7=1 —.D—REDOE ENGINEERING CO. Ity t ,,�,.... ._ CLIENT._.,....._ 1 CERTIFY THAT THE PROPOSED ;. EOISTERE REOIETERED JOB,NO. S 4"0 a-3, BUILDING SHOWN ON THIS PLAN ... .' 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