HomeMy WebLinkAbout0026 BRISTOL AVENUE - Health 26 BRISTOL AVE., HYANNIS
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 26 Bristol Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-6-14
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.
A. General Information
u �
1. Inspector: �I
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
3-6-14
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 is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
LoWrrm:
t5ins-3/13 Tdle 5 Official Insprface Sewage Disposal System-Page 1 of 17
` I
Commonwealth of Massachusetts Ili
uTitle 5 Official .Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments j
26 Bristol Ave
lg —
Property Address
Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-6-14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes: '
® I have not found any information which indicates that any of the.failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available. '
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments .
°M 26 Bristol Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-6-14
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed . ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:.
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Bristol Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-6-14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
i
D) System Failure Criteria Applicable to All Systems:
I
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® ' Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Bristol Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-6-14
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion'of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
I
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
- Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Bristol Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Hyannis MA 02601 3-6-14
required for every y
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check-if the following have been done. You must indicate "yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facilty 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)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 26 Bristol Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-6-14
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Detail:
I
Sump pump? ❑ Yes ® No
Last date of occupancy: 12-2013
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
i
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3M 3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
i
Commonwealth of Massachusetts
Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Bristol Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-6-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) and a copy of latest
inspection of the I/.A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sysiem-Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 26 Bristol Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner. Owner's Name
information is required for every Hyannis MA 02601 3-6-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1999
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 16" at tank inlet
feet
Material of construction:
® cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Good condition.
Septic Tank(locate on site plan):
8"
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gal
Sludge depth:
12"
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official- Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Bristol Ave
Property Address
Bank Owned (Contact David Holt I@ Today Real Estate 1-800-966-2448).
Owner Owner's Name
information is required for every Hyannis MA 02601 3-6-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness 2" at tank outlet
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
15"
How were dimensions determined? Tape
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Commonwealth of Massachusetts
v Title 5 Official, Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Bristol Ave
Property Address
Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-6-14
page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 26 Bristol Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis t MA 02601 3-6-14
page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Good condition with water at working level and no sign of back-up from chambers.
Pump Chamber(locate on site plan):
.Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No'
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form,-Not for Voluntary Assessments
M 26 Bristol Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-6-14
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type.
❑ leaching pits number:
® leaching chambers number: 2-500's
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields %number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach chambers in good condition and empty at inspection with stain line at 12" below inlet invert.
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
t5ins•3113 Title 5 Official Inspecton Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Bristol Ave
Property Address
Bank Owned (Contact David Holt c@ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is ,
required for every Hyannis MA 02601 3-6-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cost.) I -
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
26 Bristol Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-6-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
Ca C
E0 303
I?
�- -4 �' o
t5ins•3/13 Title 5 Official Inspedon Form:Subsurface Sewage Disposal System-Page 15 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System'Form -Not for Voluntary Assessments -
'~ 26 Bristol Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for every Hyannis MA 02601 3-6-14
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 12
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:
Original design plans show no groundwater at 12'.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal Systen-Page 16 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
26 Bristol Ave
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is Hyannis MA 02601 3-6-14
required for every H y �
page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
I
I
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
b\a cc,&O
\ COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION e
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: Bristol Avenue
_Hyannis i
Owner's Name: Wm Drew/John Drew
Owner's Address: _PO Box 487 3l
¢ IT)
O
Date of Inspection: _ �p �/ 016a7
Name of inspector.(please print) Sean Jones
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1084
Centerville, MA
Telephone Number: ( S08) 77S-8776
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of 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 CNIR 15.000). The system:
Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: `1 od
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heathy
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 how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2006 page 1
Pagc 2 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address.• 26 Bristol Avenue
I
Hyannis
Owner: Win Drew John Drew
Date of Inspection: 07
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. Sys( Passes:
1 have not found any information which indicates that any of the failure criteria described in 310 CMP'
15.303 or in 310 CMR 15.304 ektst'Any failure criteria not evaluated arc indicated below.
Comments:
B. System Conditionally Passes: /\1I A
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements.if Mot determined"please
explain.
The septic tank is metal and over 20 years old"or the septic tank(whether meta;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 twbroken or
obstructed pipes)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 teptaced
ND explain:
The system required pumping more than 4 times a year date to broken or obstrivacd pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is remorod
ND explain:
i
Page 3 of 1 I
I -
OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 26 Bristol Avenue
Hyannis
Owner: Wm Drew John Drew
Date of Inspection:
C. Further Evaluation is Required by the Board of Health;
Conditions exist which require further evaluation by the Board of Health in order to 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.aod 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 i of a public water supply.
I
— 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 front a
private water supply well— Method used to determine distance
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria arc triggered.A copy of the analysis must be attached to this form.
3. Other:
3
Pagc 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 26 Bristol Avenue
Hyannis
Owner: Wm Drew John Drew
Date of Inspection: k -7
D. System Failure Criteria applicable to all systems:
You must indicate`des"or"no"to each of the following for all'inspections:
Yes No
Backup of sewage into facility or system component:due to overloaded or clogged SAS or cesspool
_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
/clogged SAS or cesspool
Static liquid level in the distribution box above.outtet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Numbcr
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
J water supply.
_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
/Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private xater
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.]
� `j" (Yes/No)The system fails.I have determined that one or more o(the above failure criteria exist as
described in 310 CMR 15.303.therefore the system faits.The system owner should contact the Board-of
Health to determine what will be necessary to correct the failure.
E. Large Systems: nJ �f
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:
("Ilse 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 smfaoe drutking water supply
the system is located in a nitrogen sensitive area(Inaxim Wellhead Protection Area—iWPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Sertinn E the system is considered a significant threat,or answered
"yes"in Section D above the large system has failed.The owncr trr operator of arty 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 I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 26 Bristol Avenue
Hyannis
Owner: Wm Drew/John Drew
Date of Inspection:
Check if the following have been done.You must indicate`fires"or"no"as to each of the following:
Yes No/
Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
Has the system received normal flows in'the previous two week period?
/
Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the system obtained and examined?(If they were not available note as N/A)
Was the facility or dwelling inspected for signs of sewage back up?
Was the site inspected for signs of break out?
_✓ Were all system components,excluding the SAS,located on site 7
— 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 7
_✓_ 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
V" 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)13 10 CMR 15.302(3)(b)J
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: 26 Bristol Avenue
Hyannis
Owner: arm Drew/John Drew
Date of Inspection:
�'-FL CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 9
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x It of bedrooms): 3 3r- 6AO
Number of current residents: 47
Does residence have a garbage grinder(yes br no):-f-10
Is laundry on a separate sewage system(yes or no):4L,�_ [if yes separate inspection required]
Laundry system inspected(yes or no)jq
Seasonal use:(yes or no):_p�fl
Water meter readings,if available(last 2 years usage(gpd)): 2005 — 181,750
Sump pump(yes or no):NO 2006 — 17,250
Last date of occupancy:
COMMERCIALIINDUSTRIAL N
Type of establishment:
Design flow(based on 310 CUR 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): e-b
If yes,volume pumped: gallons--How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
✓Septic tank,distribution box,soil absorption system
_Single cesspool
Overflow cesspool
—_Privy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
—Tight tank Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no)-r�a
6
I'Jgc 7 s-f 1 I
OFFICIAL INSPI:MON F0101—NOT FOR VOLUNTARY ASSLSS1tIM*S
SUBSUR ACE SENVAC1; DISPOSAL SYSTEM INSPECTION F0101
PART C
S1'SI'l'm INFORA AT10N(continued)
Property Address: 26 Bristol Avenue
yannis
Owncr; Wm Drew Jo n rew
Date of Insptcllon: 5/at/
UUILUING SLIYLII(locate uu silt plan)
Depth below grade: I q5~/'
Materials of construction:_cast itun &.-'/40 PVC_uUrer(explain):
Distance from priva►c evater supply well or suction line:_
Conunetlls(on condition of juutls,veNing,evidence of leakage,etc.):
SLPTIC TANK:Z(localc on site plan)
Depth below grade: (p-r
Material of constructiun: �<:oactcle meta{ fnbeg{ass_pu{ycdiylene
_uthct(cxplain)
r- rtifiLank is metal list age:_ Is age cvnfinncd by a Certificate of Cunt iliame es or nu :! (>' ) (attach a Cully of
ccrtificalc) I)'
Dimensions: S'bD
Sludge depth:
Distance 6oisn lull of sludge to bullunt of outlet Ice of battle:
Sewn thickness: /"
Distance from lull of scum to top of uullct tee or bafllc: 6)"
Distance 6om bunum of scull,to button,of outlet nee of balllc:
I low were dimcnsiuns dctelllincd: ;,to6ted e-, -J�,,e- ,�,.�{j.�,��„���A
Cununents(un pumping tecouuuenJatiuns,inlet auJ uutict lee w bafllc conduit n,s Uoututat intcpity, liquid IcVCk
as related to outlet otvcrt,evidence of leakage,etc.):
�v Jt� �•� a.}rl�{- �Rc�i -.si=c,!• w.n-icr .c.,c.r ,t� ba7t�a�-. ctL' a�`1-t!c�-
GIIE,ASL TRA1' _(locate vu site plant)
Dcpdi below grade:_
Malciial of consumcliun:—kolicictc meta) fibciglass_pulyctltyknc__olhcr
(oplain):
Dimensions:
Scunt thickness:
Distance frou,lop of scull,to lop of owlet tcc or bafllc: _
Distance from buttum of scum to buttun,of outlet tee or Wilt:
Date of last pumping:
Conunenls(oil pumping Iecumntc lid aliuns,inlet and outlet Ice or balllc sit uctmal inkpily.liquid Icvch
as Iclalcd to oullct ilIMI.cvidcncc of leakage,cic.):
7
1'agc 8 of I 1
I
OFFICIAL INSPECTION FORM—NOT 1;01t VOLUNTARY ASSESSNIENTS
SUBSUIU-ACI; SEIN'AGE UISI'OSALSYS7•ENI INSPi;CT10N FORNI
I'ART C
SYSTEM INFORMATION(continued)
Properly Address: 26 Bristol Avenue
Hyannis
Owner. Win Dr,,! n Drew
Wit of lospcctlou:
e
TIGHT or IIOLllING TANKN (tmtk mtust be pun►ped at I""C of inspecliun)(lucale un site plan)
Depilt below grade:
Material of construction:__cuncrcle_tttetal_fiberglass_�rulyethyltrte othes(explain):
Uintcnsions:
Capacity:— altuns
Ucsign Flow: gallons/Jay
Alarm prescnl(yes ur no):
Alarm level: Alann in wutkin urdcr
Ualc of last pumping: g V"cs ur nu):
Cununcnis(condition of alarm and lluat switches,cic_):
UISTKIUUTION IIOX: %/(ifpresent ilrust be opencd)(locate on site plan)
Dcpth of liquid level above outlet invert: Z)i[
ColluIcaka c Into
(note if box is level: disbiLutiull to outlets cquaB,any evidence of solids carryover,any evidence of
Ical:a•c into or out of box,cicJ:
PUMP CIIAMUL1t:kuucale on site plan)
Pumps in wurking order(yes or nu):_
Alanns in working order(yes us no):_
Curnutcnls(note condition of pump cbautbcr,ctuulitiun of puiaps and apputtcnan(cs,cic.):
Page 9 of I I
OFFICIAL INSPECTION.FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 26 Bristol Avenue
Hyannis
Owner. Wm Drew John 'Drew
Date of Inspection: 9/41
SOIL'ABSORPTION SYSTEM(SAS): (locate on site plan,excavation'not required)
If SAS not located explain why:
Type
leaching pits,number:_
7_leaching chambers,number
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number.
innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
dry
CESSPOOLS: N/ (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.):
N (�
PRIM. (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.):
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: 26 Bristol Avenue
Hyannis
Owner: Wm Drew/John Drew
Date of Inspection: 4 7
I
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including.ties to at least two permanent reference landmarks or
benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.
I
i
I
RCA
L v o
7 ArJ 1_
A- ! 2�
D-9
/A-a 3b
3'a as
SAS
6-3 ab '
10
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Page I I.of 11 ,
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address- 26 Bristol Avenue
Hyannis
Owner. Wm Drew/John Drew
Date.of Inspection: a����
--r
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:
Cana..d eJ.; 1w. Cs i•�Gl.skt�1 e rrs. �,•., aF i ns hb i2
r"
11
Town of Barnstable
OF 1HE Tp�
Regulatory Services
sMxrrsrnsi a Thomas F. Geiler, Director
y MAS&
$ 16s9. p Public Health Division
ATED��
Thomas McKean, Director
i
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition, by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the"Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
I
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i �
TOWN OF BARNSTABLE C
S Q N V SEWAGE #LOCATION C�
VILLAGE ASSESSOR'S MAP & LOT U
INSTALLER'S NAME&PHONE NO. �Ob S o 7 S- 'F 7 74�
SEPTIC TANK CAPACITY 8 0
LEACHING FACII.ITY: (type) �— S-9^�-� (size)
NO.OF BEDROOMS n
BUILDER OR OWNER U'IT i`C4J
PERMITDATE: -t2-0" 7 GI COMPLIANCE DATE:/b" 1
Separation Distance Between the:
i
Maximum Adjusted Groundwater Table to the Bottom of Leaching cility Feet
Private Water Supply Welland Leaching Facility (If any we exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands xist
within 300 feet of leaching facility) Feet
Furnished by
a
a
I
II
-A
No. 9,
Fee 0
15
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
ZppYication for �N_4pogar *pgtem Construction Vertu
Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 26 Bristol Ave . , 070erA N,Iamb Adedre
Assessor's Map/Parcel ss and Tel.No.
Hyannis , MA 26 Bristol Ave . , Hyannis
annis
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
lfflm. E. Robinson Septic Service
P.O . Box 1089, Centerville , MA
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
..Size of Septic Tank Type of S.A.S.
+ Description of Soil S and.
Nature of Repairs orAlater�tio�b(Q►ns�we�whetalicab ) New Title 5 system consistirg of .
U a
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this B and of Heal ✓��v�
Signed k _ Date
Application Approved by Date l•S,
Application Disapproved for the olio ng reasons
Permit No. Date Issued
No. a L 3 Fee $5 0
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipplication for Migozal *p$tem Construction Permit
Application for a Permit to Construct( )Repair(X)Upgrade( )Abandon( ) El Complete System El Individual Components
Location Addressor Lot No. 26 Bristol Ave . , Owd� ManbPidws and Tel.No.
Hyannis , MA
Assessor's Map/PMap/Parcel �216 Bristol Ave . , Hyannis
Installer's Name,Add sg,and Tel.No. Designer's Name,.Address and Tel.No.
WT �E. Robinson Septic Service
P.O . Box 1089, Centerville , MA
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons i Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
..x-• Description of Soil Sand.
' New Title 5 system consisting of
Nature of Repairs or Alter do n wh cab ) w
Date last inspected:
Agreement:-
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
' in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by th' Bard of Healt
Signed i 1 Date
Application Approved by
Application Disapproved for the ollowmg reasons '
J
Permit No. 'Lj Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
Drew BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO C IRTIF ,that ob 1n on evSyagg Pp 80'la Ays�t11�onstructed( )Repaired( X )Upgraded( )
Abandoned( )by ��
at 26 Bristol Ave . , Hyannis , MA has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. ,- L t dated
Installer Wm. E . Robinson Septic S ery is eDesigner
!�— The issuance of this6pert4tt shall not be construed as a guarantee that theys., Im will functio �S esi d.
} Date �1 Inspector 1 /
t 1 v
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I
———-`----—-------------------—--- —
Fee $50
No. THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Drew
Mizpooar 6potem Construction Permit
Permission is hereb anted to Construct( )Repair(X )Upgrade( )Abandon( )
System located at �19 Bristol Ave . , Hyannis , MA
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: Approved by Q ,�
TOWN OF BARNS'T/ABLE
LOCATION �� !{ S J d• V SEWAGE #
VILLAGE �vA�-� 3
1/ ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. UO �.S o „- 7 7
SEPTIC TANK CAPACITY 4 6-0
LEACHING FACILITY: (type) �- �-9-�- J L (size) ,[,�.Z�-,i�
NO.OF BEDROOMS
BUILDER OR OWNER_ � 4`(•c.�
PERMITDATE: "�-a''Ol �'f COMPLIANCE DATE:--1 d- 5
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching F cility Feet
Private Water Supply Well and Leaching Facility (If any we exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands xist
within 300 feet of leaching facility) Feet
Furnished by
i
i
t
?1.5�d
y' 7t
NOTICE: This Form Is To Be Used For The Repair Of Failed
Septic Systems Only.
b
3 i 6 �
CERTIFICATION OF SKETCH AND.APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT.(WITHOUT
ENGINEERED PLANS)
I, William E. Robinson, Sr. ,hereby certify that the application for disposal works
construction permit signed by me dated 9 concerning the
property located at 26 Bristol Ave., Hyannis, MA meets all of the
following criteria:
*Mere are no wetlands within 100 feet of the proposed leaching facility.
*% tre are no private wells within 150 feet of the proposed septic system.
There is no increase in flow and/or change in use proposed.
/There are no variances requested or needed.
* If the proposed leaching facility will be located with 250 feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S. map) _
B)Observed Groundwater Table Evaluation(according to Health Division well map)
—
SIGNED: 1 DATE
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60
(Attach a sketch plan of the proposed system. Also if the licensed installer posesses a certified plot plan,
this plan should be submitted).
I
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