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Home My WebLink About0220 BUCKWOOD DRIVE - Health J 220 Buckwood'Drive Hyannis 1-105 E r 7-/-/as Commonwealth of Massachusetts o? � W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M M 220 Buckwood Dr. Property Address PQ Mike Davis3 Owner Owner's Name information is required for every Hyannis V1 MA 02601 8/24/2017 � 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 A. General Information < filling out forms c� /# /a 600 on the computer, use only the tab 1. Inspector: key to move your cursor-do not Paul Martin use the return Name of Inspector key. Cape Cod Septic Services Company Name 350 Main St Company Address W.Yarmouth MA 02673 City/Town State Zip Code 508-775-2825 S15016 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 - 9/1/2017 Inspector's ignature 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. t5ins-3/13 Title 5 Official Inspection F%m:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts N W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 8/24/2017 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: System in working condition. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 8/24/2017 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments G M ,•°°y 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 8/24/2017 page. City/Town 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: D) 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 ❑ ® 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/z day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 8/24/2017 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑' ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within,400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 8/24/2017 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner) provided with ® ❑ information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 110x4= 440gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 8/24/2017 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 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)): None Available Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis`of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 8/24/2017 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: No records 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 l/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 8/24/2017 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1986 and 1995 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 22"feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: +10'feet Comments (on condition of joints, venting, evidence of leakage, etc.): Line checked with sewer camera and was found to be clean, properly pitched with no sign of root intrusion. Septic Tank (locate on site plan): .Depth below grade: 12feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1f tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000Gal Sludge depth: 3-5 t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 8/24/2017 page. CitylTown 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 Scum thickness 1-2 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle , How were dimensions determined? Estimated Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 1000Gal tank in good condition. PVC tees in place and clean. Tank at normal operating level. Covers 12" below grade. 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 8/24/2017 page. City/Town 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 8/24/2017 page. CitylTown 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 011 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.): H-10 DB-3 with 1 line in and 2 lines out in good condition. Box showing wear but still intact. Outlet inverts equal. No sign of overloading or hydraulic failure. Cover 24" below grade. 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.pumpsoor 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 GSM ,•°' 220-Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 . 8/24/2017 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ 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.): 2-Leach pits. 1-6x4 and 1 6x6 pit. Older pit was found dry with newer pit with 1' of effluent. No evidence of overloading or hydraulic failure. 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 Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 8/24/2017 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 8/24/2017 page. City/Town 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 l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is required for every Hyannis MA 02601 8/24/2017 page. City/Town 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: Hand auger 4' below dry pit with no water encountered. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °�M ,•' 220 Buckwood Dr. Property Address Mike Davis Owner Owner's Name information is Hyannis MA 02601 8/24/2017 required for every 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 T �tl i r _ QC4\ - " I� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Ixf Arlene Lejava Property Address 220 Buckwood Ave. Owner Owner's Name information is required for every Hyannis MA 02632 8/2/2013 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your ? 15 cursor- not James Ford U use the return urn key. Name of Inspector f /.rab Company Name P.O. Box 49 Company Address Osterville MA 02655 City/Town State Zip Code 508-862-9400 S 12482 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this add es and thaTthe A information reported below is true, accurate and complete as of the time of the�iijls!pection. Tt;e insp'iction was performed based on my training and experience in the proper function and`mrnpintenandVof oQite sewage disposal systems. I am a DEP approved system inspector pursuanttito'Sectionf'%349hf Title 5(310 CMR 15.000). The system: ® Passes ElConditionally Passes ❑ Fails i ❑ Needs Furt a Evaluation by the Local Approving Authority ry r 8/16/13 Insp to r's Signatur Date The stem 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. r. ****This report only describe:!`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. d t5ins•3113 Title 5 Officialo :Subsurface Sewage Disposal System•Page 1 of 17 l 9 f Commonwealth of MasscIchusetts Title 5 Official Inspection Form Subsurface Sewage Disposal-System Form -Not for Voluntary Assessments a Arlene Lejava 4' Property Address 220 Buckwood Ave. Owner Owner's Name information is Hyannis MA 02632 8/2/2013 required for every y 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: 9 ® 1 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: r 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. r . Check the box for"yes", "no"or",not determined" (Y, N, ND)for the following statements. If"not determined," please explain., i The septic tank is metal an"d.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): r ' 15ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 0 it Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a2 Arlene Lejava ". Property Address 220 Buckwood Ave. Owner Owner's Name �• information is required for every Hyannis MA 02632 8/2/2013 page. Cityrrown State Zip Code Date of Inspection B. Certification (Cont), ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with'approval of Board of Health): t Ej broken pipe(s)'lare 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 pipes){are replaced ❑ Y ❑ N ❑ ND (Explain below): 41 ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): F , i! 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 prfivy is within 50 feet of a bordering vegetated wetland or a salt marsh l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 t . Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage DisposaliSystem Form - Not for Voluntary Assessments t a Arlene Lejava Property Address 220 Buckwood Ave. Owner Owner's Name information is required for every Hyannis MA 02632 8/2/2013 page. CitylTown it 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. i ❑ 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 i , t D) 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 ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2.day flow 15ins-3/13 i Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 t i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Arlene Lejava Property Address 220 Buckwood Ave. 1 v . Owner Owner's Name information is required for every Hyannis MA 02632 8/2/2013 page. City/Town State Zip Code Date of Inspection B. Certification (Cont.)e . 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. ❑ Z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a.surface water supply. ❑ Z. 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 c i hain of custody must be attached to this form.] ; ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria:exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd,to 15,000 gpd. For large systems, you must.indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area -IWPA)or a mapped Zone II of a public water supply well If you have answered "yes"to..any question in Section E the system is considered a significant threat, r 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 1 �i Commonwealth of Massachusetts Title 5 Official, Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Arlene Lejava Property Address 220 Buckwood Ave. Owner Owner's Name information is g required for every Hyannis MA _ 02632 8/2/2013 page. Cityrrown r 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 r ` ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were anytof 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 a's 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? ❑ z Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The sie 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)] J D. System Informaticl,n' Residential Flow Conditions: 9 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 Fora Subsurface Sewage Disposal,System Form - Not for Voluntary Assessments °M Arlene Lejava Property Address 220 Buckwood Ave. Owner Owner's Name information is required for every Hyannis MA 02632 8/2/2013 page. Citylrown State Zip Code Date of Inspection D. System Informatioo r ; Description: t ei l 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 1 . Water meter readings, if available(last 2 years usage (gpd)): Detail: unavailable t 4 .. q ' Sump pump? ❑ Yes ® No is Last date of occupancy: unknown 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/p.ersons/sq.ft., etc.): Grease trap present? „ El Yes ❑ No il . Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? El Yes ❑ No t Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official; Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a Arlene Lejava Property Address r 220 Buckwood Ave. Owner Owner's Name information is required for every Hyannis MA 02632 8/2/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date f Other(describe below): r General Information Pumping Records: 'Source of information: unavailable Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? maintenance 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 El Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments e,• Arlene Lejava Property Address 220 Buckwood Ave. Owner Owner's Name information is required for every Hyannis MA 02632 8/2/2013 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: installed -unknown date. newer pit was added Were sewage odors detected when arriving at the site? ❑ Yes ® No r . . Building Sewer(locate on'site plan): p Depth below grade: °. 16" feet Material of construction: , al t. ❑ cast iron ® 40`PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments (on condition ofjoints,.venting, evidence of leakage, etc.): 1 P Septic Tank (locate on site;plan): 12" Depth below grade: feet Material of construction: M Y t� ® concrete ❑ metal ❑ fiberglass ❑ polyethylene y El other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No i Dimensions: r 1000 gal. Sludge depth: 2„ t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 :i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a Arlene Lejava Property Address 220 Buckwood Ave. Owner Owner's Name information is required for every Hyannis MA 02632 8/2/2013 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 15 Scum thickness 12 Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 8" How were dimensions deterinined? Measured Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to out invert, evidence of leakage, etc.): There were no signs of leakage. Recommend pumping every 3 years. Grease Trap (locate on site plan): Depth below grade: {' feet Material of construction: ❑ concrete ❑ metal. ❑fiberglass ❑ polyethylene ❑ other(explain): N/a t r 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a Arlene Lejava Property Address y 220 Buckwood Ave. Owner information is Owner's Name required for every Hyannis MA 02632 8/2/2013 page. City/Town State ZipCode 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.): :t Tight or Holding Tank(tanrk must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): N/a Dimensions: I i Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: r Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date s 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 Ilnspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Arlene Lejava Property Address 220 Buckwood Ave. ` Owner Owner's Name information is required for every Hyannis MA 02632 8/2/2013 page. City/Town 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 even Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): The liquid level in the D- box was normal. The cover was 24" below i' y 1 Pump Chamber(locate on''site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: x ❑ Yes ❑ No* Comments (note.condition of pump.chamber, condition of pumps and appurtenances, etc.): N/a * 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 Arlene Lejava Property Address 220 Buckwood Ave. Owner Owner's Name information is required for every Hyannis MA 02632 13 page. City/Town 8/ —f State Zip Code Dat teeo of Inspection D. System Information (cont.) Type: ® leaching pits; number: 2 -6'x6' 1000 Ral. ❑ leaching chambers number: ❑ Teaching 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.): The pit was dry. There were:no signs of failure. A camera was used for the inspection Cesspools (cesspool must lie pumped as, part of inspection) (locate on site plan): Number and configuration N/a Depth=top of liquid to inlet invert Depth of solids layer Depth of scum layer a _ Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 • 11 Commonwealth.of Massachusetts r Title 5 Official inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments i. °�M A,•y'' Arlene Lejava Property Address 220 Buckwood Ave. Owner information is Owner's Name required for every Hyannis MA 02632 8/2/2013 page. City/Town State Zip Code Date of Inspection D. System Informatio"r (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t. 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.): N/a 1 is (Sins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 i , N Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Arlene Lejava Property Address 220 Buckwood Ave. Owner Owner's Name information is required for every Hyannis MA 02632 8/2/2013 page. Cltyrrown 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 A (3 AGk a 3 a � 01 3 as a � y3 3S i t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 r , • • • . Commonwealth of Massachusetts • W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °�M •'�e Arlene Lejava Property Address 220 Buckwood Ave. Owner Owner's Name information is required for every Hyannis MA 02632 8/2/2013 page. City/Town 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: 40' 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: Using topo and water contours maps I ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database -explain:. i You must describe how you.established the high ground water elevation: groundwater is not an issue at this site r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposa(System Form - Not for Voluntary Assessments Arlene Le'ava a � Property Address 220 Buckwood Ave. Owner Owner's Name Information is required for every Hyannis MA 02632 8/2/2013 page. Cltyrrown 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 P 1 k 7 fl t' 7 l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal system•Page 17 of 17 4 > TOWN OF BARNSTABLE 4 Anornved. 25� _ BOARD OF HEALTH lbli_ ' Cert:TIN, - 0 ARTICLE II:MINIMUM STANDARDS FOR HUMAN HABITATION Date -1 2 51 10 Time: In G�IS Out Owner fz L t u l-E A-,/A Tenant ' 2;L \/1AST Aiwa✓ i 11'/L1'S7ini.,X -1 v4A..v�Jq. 2 Z� so C'v-,4 'o V a Address 1 y-11 1''1 NBC L/V Address Z &3 2 .s ,ti, 4 Compliance Remarks or Regulation# Yes NO Recommendations 2. Kitchen Facilities 3. Bathroom Facilities 4. Water Supply 5. Hot Water Facilities 0a 6. Heating Facilities 7. Lighting and Electrical Facilities 8. Ventilation o t- 1 9. Installation and Maintenance of Facilities —7 v-,—t 10*.s 10. Curtailment of Service Cab�f 2V it 0 11. Space and Use 1 LZ d 10 , 12. Exits 13. Installation and Maintenance of Structural Elements 14. Insects and Rodents 15. Garbage and Rubbish Storage and Disposal 16. Sewage Disposal Q W A-t C 17.Temporary Housing 18. Driveway Width 19. Number of Tenants Observed PART II 37. Placarding of Condemned Dwelling; Removal of Occupants; Demolition "w f6 Number of Bedrooms Z4 kit G Number of Vehicles Allowed (max) Ted Number of Persons Allowed (max) Person(s) Interviewed Inspector S If Public Building such as Store or Hotel/Motel specify here s FORM 30 C&w H088S&WARREN in THE COMMONWEALTH OF MASSACHUSETTS ,;�q, BOARD OF HEALTH ST MsG E CITY/TOW N W DEPARTMENT 'a 200MA, ea ST. 4A-1 .- z s t►-� ADDRESS C-SLE—PHO Address 2 Z �0,t�dt�ccupant_C 912� Pa Floor Apartmen No.--_ N&of Occupants cS No.of Habitable Rooms 42 No.Sleeping Rooms q No.dwelling or rooming units r. No.Stories ^ �/J /�JName and address of owner ] %C Ku A-tn__ L( XpyA �. 1`i� �7S-(�Z 13 '�1 (z NOS[ ` I W f." `-AN CjL"-CtA\J%LL4_ Remarks Reg. Vio. YARD Out Bld s.: Fences: / Garbage and Rubbish vContainers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: Roof Gutters, Drains: Walls: Foundation: Chimney: BASEMENT Gen.Sanitation: Dampness: Stairs: Li htin : STRUCTURE INT. Hall,Stairway: _I1 (,// Hall, Floor,Wall,Ceiling: Hall Lighting: Hall Windows: HEATING Chimneys: Central ❑ Y ❑ N Equip. Repair TYPE: Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST'/❑ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRIC Panels, Meters,Cir.: ❑ 110 Ef220 Fusing,Grnd.: AMP: Gen.Cond. Distrib. Box.- Gen. Basement Wiring: DWELLING UNIT Ventil. L to Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen Bathroom Pantry Den Living Room Bedroom 1 s Bedroom 2 Q Bedroom 3 Bedroom 4 Hot Water Facil. Su Stacks, Flues,Vents,Safeties: Kitchen Facilities Sink Stove Bathing,Toilet F il. Vent., Plumb., asin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: General Building Posted POST Locks on Doors: ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND IIII PENALTIES PERJURY " . ry INSPECTOR 7 TITLE ' DATE 7 2 TIME /0 �O 0 A. . A.M. THE NEXT SCHEDULED REINSPECTION �/�/ P.M. 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises,shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore,is"not included in this listing. Failure to include shall in no way'be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water.sufficient.in'quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain'a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. f (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements-of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish,filth or other causes of sickness which may provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2) and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or,any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. ' '� 4'M"irrotir:.'w.�"*.d4M.-...,iir'?+'+� 'MA.IN +••""C, seu• �...n'#....•✓F.S,s✓+G„rs;"^."•rwy'^''. 1.01 K~ FORM30� C� " THE COMMONWEALTH OF MASSACHUSETTS FI&w HOBBs 8 WARREN + + B O A R D 'O F HEALTH ` � `. �n 2t_-. S"t a�L 1� CITY/TOWN � I _ W �l res k.—r i-c DEPARTMENT ADDRESS — 4�M svey`0 A 4. C� � e(-? -. a 40 C.(cl ELEPHONE v w Address 7-b (4 i. l , o! �A4AtaNiDccupant C1A-_" r P4— Floor •- Apartment No. _ No.of Occupants No.of Habitable Rooms G No.Sleeping Rooms !q No.dwelling or rooming units -- No.Stories ` Name a-npd' address�oof owner �� hQ � ��„ � S��i p, �5�� '�7.5- , 7 1 3 lJ� NG 1 l t' I f� f�. �- �► f t-32 tt 4\11 L.L?L hMAA. Remarks- Reg. Vio. YARD Out Bld s.: Fences: • Garbage and Rubbish Containers: Drainage Infestation Rats or other: STRUCTURE EXT. Steps,Stairs, Porches: Dual Egress:and Obst'n.: ❑ B ❑ F ❑ M Doors,Windows: �--� ' Roof Gutters, Drains: Vol* Walls: Foundation: 1 / V Chimney: BASEMENT Gen.Sanitation: T,. Dampness: Stairs: 1 Li htin cr• .� STRUCTURE INT. Hall,Stairway: v ` ' i• Obst'n.: Hall, Floor-,Wall.4C,ellln. . Hall Lighting: - Hall Windows: HEATING Chimneys: E Central ❑ Y ❑ N Equip. Repair TYPE: } Stacks, Flues,Vents: PLUMBING: Supply Line: ❑ MS ❑ ST/ P Waste Line: H.W.Tanks Safety and Vent(s) ELECTRIC�4- Panels, Meters,Cir.: ❑ 110 CY220 Fusing,Grnd.: ,,R> AMP: Gen.Cond. Distrib. Box: Gen. Basement Wiring: DWELLING UNIT Ventil. L to . Outlets Walls Ceils. Wind. Doors Floors Locks Kitchen. t.4 t Bathroom Pantry Den V ! Living Room Bedroom 1 O S Bedroom 2 too Bedroom 3 � Bedroom 4 15 S Hot Water Facil. Su_,._-en�Gass,, Oil ---Stacks, Flues,Vents,Safeties:. Kitchen Facilities Sink /( d ' Stove 'Bathing,Toilet 4—,cil. Vent., Plumb.,Sanat<n-. �,. ash-Basin,Shower or Tub: Infestation Rats, Mice, Roaches or Other: Egress Dual and Obst'n: f General Building Posted G ST IE Q Locks on Doors: 1 � ONE OR MORE OF THE VIOLATIONS CHECKED ABOVE IS A.CONDITION WHICH MAY MATERIALLY IMPAIR THE HEALTH OR SAFETY AND WELL-BEING OF THE OCCUPANT AS DETERMINED BY 105CMR 410.750 OF THE CODE OR THE AUTHORIZED INSPECTOR.(See Over) "THIS INSPECTION REPORT IS SIGNED AND CERTIFIED UNDER THE PAINS AND PENALTIES OF-PERJURY." t INSPECTOR ( TITLE AF a A.M. ;r7 DATE / fi 4 r7 TIME A C)C> P:M. ` J THE NEXT SCHEDULED REINSPECTION N j / P.M. Y - _ �.«.. y. ..�..r::'._^.'F _..,,,r_ _. r _r-. r .. ..._. ♦a.,._may. ..'.YRr..• Il'�+�-w^ .lrr'uv'�w.�.fr r'Yr1.� _ _ �;.Aa�.. '4....Y.re Y..— trr.= T r r 410.750: Conditions Deemed to Endanger or Impair Health or Safety The following conditions,when found to exist in residential premises, shall be deemed conditions which may endanger or impair the health, or safety and well-being of a person or persons occupying the premises.This listing is composed of those items which are deemed to always have the potential to endanger or materially impair the health or safety, and well-being of the occupants or the public. Because Chapter 11, 105 CMR 410.100 through 410.620 state minimum requirements of fitness for human habitation, any other violation has the potential to fall within this category in any given specific situation but may not do so in every case and therefore is not included in this listing. Failure to include shall in no way be construed as a determination that other violations or conditions may not be found to fall within this category. Nor shall failure to include affect the duty of the local health official to order repair or correction of such violation(s) pursuant to 105 CMR 410.830 through 410.833 nor shall failure to include affect the legal obligation of the person to whom the order is issued to comply with such order. (A) Failure to provide a supply of water sufficient in quantity, pressure and temperature, both hot and cold, to meet the ordinary needs of the occupant in accordance with 105 CMR 410.180 and 410.190 for a period of 24 hours or longer. (B) Failure to provide heat as required by 105 CMR 410.201 or improper venting or use of a space heater or water heater as prohibited by 105 CMR 410.200(B)and 410.202. (C) Shutoff and/or failure to restore electricity or gas. (D) Failure to provide the electrical facilities required by 105 CMR 410.250(B), 410.251(A), 410.253 and the lighting in com- mon area required by 105 CMR 410.254. (E) Failure to provide a safe supply of water. (F) Failure to provide a toilet and maintain a sewage disposal system in operable condition as required by 105 CMR 410.150(A)(1)and 410.300. (G) Failure to provide adequate exits, or the obstruction of any exit, passageway or common area caused by any object, including garbage or trash,which prevents egress in case of an emergency 105 CMR 410.450, 410.451 and 410.452. (H) Failure to comply with the security requirements of 105 CMR 410.480(D). (1) Failure to comply with any provisions of 105 CMR 410.600, 410.601 or 410.602 which results in any accumulation of gar- bage, rubbish, filth or other causes of sickness which may,provide a food source or harborage for rodents, insects or other pests or otherwise contribute to accidents or to the creation or spread of disease. (J) The presence of leadbased paint on a dwelling or dwelling unit in violation of the Massachusetts Department of Public Health Regulations for Lead Poisoning Prevention and Control, 105 CMR 460.000. (See M.G.L. c. 111 @@ 190 through 199.) (K) Roof,foundation, or other structural defects that may expose the occupant or anyone else to fire, burns, shock, accident or other dangers or impairment to health or safety. (L) Failure to install electrical, plumbing, heating and gas-burning facilities in accordance with accepted plumbing, heating, gas-fitting and electrical wiring standards or failure to maintain such facilties as are required by 105 CMR 410.351 and 410.352, so as to expose the occupant or anyone else to fire, burns, shock, accident or other danger or impairment to health or safety. (M) Any defect in asbestos material used as insulation or covering on a pipe, boiler or furnace which may result in the release of asbestos dust or which may result in the release of powdered, crumbled or pulverized asbestos material in violation of 105 CMR 410.353. (N) Failure to provide a smoke detector required by 105 CMR 410.482. (0) Any of the following conditions which remain uncorrected for a period of five or more days following the notice to or knowledge of the owner of said condition or conditions: (1) Lack of a kitchen sink of sufficient size and capacity for washing dishes and kitchen utensils or lack of a stove and oven or any defect that renders either inoperable. (2) Failure to provide a washbasin and shower or bathtub as required in 105 CMR 410.150(A)(2)and 410.150(A)(3)or any defect which renders them inoperable. (3) Any defect in the electrical, plumbing or heating system which makes such system or any part thereof in violation of generally accepted plumbing, heating, gasfitting, or electrical wiring standards that do not create an immediate hazard. (4) Failure to maintain a safe handrail or protective railing for every stairway, porch balcony, roof or similar place as required by 105 CMR 410.503(A)and 410.503(B). (5) Failure to eliminate rodents, cockroaches, insect infestations and other pests as required by 105 CMR 410.550. (P) Any other violation of 105 CMR 410.000 not enumerated in 105 CMR 410.750(A)through (0)shall be deemed to be a con- dition which may endanger or materially impair the health or safety and well-being of an occupant upon the failure of the owner to remedy said condition within the time so ordered by the Board of Health. TOWN OF BARNSTABLE LOCATION '�90 _RVC<c,yQoO VyOt SEWAGE # VILLAGE 0-ti ii i S ASSESSOR'S MAP &LOT INSTALLER'S NAME&PHONE NO. _ SEPTIC TANK CAPACITY f(20 0 LEACHING FACILITY: (type) '��S (size) /D®O NO.OF BEDROOMS BUILDER O OWNER PERMTTDATE: - COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells-exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet f l�a�hing facility) Feet Furnished by `•�/ az e� � (11n. ) �' w Ilk :9, r THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE Apphration for Dinpn!ttl Hlor1w Towarttr#ion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair kX� an Individual Sewage Disposal System at: 22D... -------------------------- ------•-----------------------•--•------------•--•-----------•-------•------_--_---•-----•------- Location-Address or Lot No. RG} r �.Y.ri-------------•-----•---------------------------------------- ---------------------------------•--------------------------•----••-------•-•-•--•---•-••----••--- Owner Address W J.P.Macomber Jr. I1istalIer Address d Type of Building Size Lot............................Sq. feet U Dwelling-X No. of Bedrooms--------------3_-__-.--_-_-__--.-_---Expansion Attic ( ) Garbage Grinder r4p ) aOther—Type of Building ------------ ----------- No. of persons---------------------------- Showers ( ) — Cafeteria ( ) Other fixtures ------------------------------- - - W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width---------------- Diameter................ Depth................ x Disposal Trench—No- -------------------- Width.................... Total Length.................... Total leaching area....................sq. ft.. Seepage Pit No--------------------- Diameter-------------------- Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I----------_--:.minutes per inch Depth of Test Pit-------------------- Depth to ground water....................... Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water--.-_-------__----_----. a -----------------------------•-•--•--------•--•----------••---- .............................................................................................. 0 Description of Soil........................................................................................................................................................................ U .........................S-and---&...G.ravel----------==.............................................................................................................................. W UNature of Repairs or Alterations—Answer when applicable..-Add---additional----leachpi-t---to---an---------- .........................exia.ting...tank...&---RIT--...................................... -------------------------------------------------------------------•----------. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place..the system in operation until a Certificate of Compliance has bee iss ed by the bo d of health. Signed-...... �. .... ---- _---- -- -. -------------------------- -----2/24-1-9-5--------- ,��''' Application.Approved B - -. -------------- - --. ---- ------------ ,�c ��" Dace Application Disapproved for the following reasons- ----------------------- ......... .................... ._......_. . ...._. .............. . ... .... - . - .. .. ..................__.. .... ..... .................... Permit No. ------9."� � ----- Issued --------.�0..". � � = Dace w... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE - Appliration- for Bbi-,p 1iia1 Works Towitrnrtinn ranfit Application is hereby made for a Permit to Construct ( ) or Repair I(Xy) an Individual Sewage Disposal System at: 22.0....Rja l iL.7noi�..n7.Axne._-Vy-as 1 s----------•................ ........................••..........---•------•-••-- Location-,A.ddress or Lot No. Richard LeJava owner AddressW J.P.Macom_ber Jr. T ----•---•---•-••••--. ....-•-••-••••--------•---••-•-----•••---------••-•------------•---•----•••- --•-----••------------------•----•---•-•-•-•--•-•-•-•-••-•---••----••••-•-••••-•-•••-•---••-••---- ,.a � Installer Address d Type of Building Size Lot............................Sq. feet Dwelling x No. of Bedrooms--------------3----------------------------Expansion.Attic ( ) Garbage Grinder r(p ) pa., Other—Type of Building ............................ No. of persons.:-------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures ............................... . . d - �. - W Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. 1:4 Septic Disposal Trench iglNo capacity........- dthils LengthTotal Length Width...........'__Total leaching area__ Depth.......sq..ft. Seepage Pit No...................... Diameter------------- ------ Depth below inlet---_................ Total leaching area..................sq. ft. len- Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water.....-..-..---_-..----.. G%, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ a ------------------ ----------------------------......................................................................................................... 0 Description of Soil------------------------------------------------------------------------------------------------------------------------------------------............................. W ......................... and--- ....Gx:iavel.....••••-•-------•---...----••••......---•-•------. W UNature of Repairs or Alterations—Answer when applicable_ ldd...ad_-ditian-a.1---I-each.p t...to..am.......... .......................... x s tine----tank... P.1-T......................................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the w system in operationfuntil a Certificate of Compliance has been issued by the bo ,rd of health. Signed /.` --2:./..2..419 5.- ....... ---------------------------- t Dare ' Application.Approved B .......... . ........... .... Date Application Disapproved for the`following reasons: .............. - .... - ... .. - - .......- f --- ----------- C� Issued '� ..... �Permit No. ...... .. .. . ............ .."--..--. � . ... . Dace THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE l v�P1tfftrate of Q-11antialtanve THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX) by -----------------------J...P.-P•lacomber....J.r..........- ----------------------------- ---....-------- ---....-------- ---- ----------------------------------..------------------------------- lncaiuer at ----------------------..2.0....Buckwood...Drive Hyannis------...----.......-----------.........------------------------------------- -------------------------------------- has been installed in accordance with the provisions of TITLE of T e State Environmental Code as described in the application for Disposal Works Construction Permit No. . . .... ------ dated Z----... 4 THE ISSUANCE OF THIS CERTIFICATE SHALL NO BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE.....................a> 1 - n/...... . ----- ----------- Inspector ------ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH G� TOWN OF BARNSTABLE FEE-- ...0-.00 Uhipntittl Workii Tuntrurtion nutit Permission is hereby granted-----J P.Macomber-•Jr.................................................... to Construct (( )) or Re air IM an Individual Sewage Disposal System 220 Buc�Cwood Dr.i.e-Jivan-n- s-.-----,-------------- Street ^` as shown on the application for Disposal Works Construction Permit ��... ....--'�� Dated-- ��. .. Board of Health DATE---------. .............. �=n�'4 ............................ FORM 36508 HOBBS&WARREN;,INC..PUBLISHERS d r -� — N1 A m cn v n -D-� o r \ = cn D n A N S _ Q J v C � /*1 D v v w+ n x a 0 Zvi IV r FJ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Application is hereby made for a Permit to Construct V) or Repair an Individual Sewage Disposal System at: Loration-Address or Lot No. 7' Installer Address Z Other Distribution box (K) Dosing tank ( ) Percolation Test Results Performed .............. Date- Agreement: ` The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TL 'L Uj 5 place the system in operation until a Qigned at Application Approved ]jy'-------------' � -----��f ° v Application Disapproved for the following roux --------.----------------_--..----'---------'..-_____----__ -------------'--'-----'--------'-'----'--'-'-----------------------------'---------'-------- ' Date PermitNn...................................................--- Issued..................................................... | --- | � '-- ' '' '''''''''-'-''''''''-''-''''''''''''' -'-'-'- No................_....... Fss......................... _ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH � G '"�C✓`.................OF..... /r. /Y-t%�! �1=� ...:::_.....---............ , ppliration for Roposal Works Tonstrnrtuan rrntit Application is hereby made for a Permit to Construct (,X) or Repair ( ) an Individual Sewage Disposal System at: Location-Address or-Lot Lot No. 7S ................................................ .............l V f / i �r� ..../.f'ri.a�./�t��.� f7 `,,n- DIE- � Owner ] Address Installer Address d Type of Building Size Lot...........................Sq. feet Dwelling—No. of Bedrooms...........�...........................Expansion Attic ( ) Garbage Grinder44 ( ) Other—T e of Building No. of persons............................ Showers — Cafeteria a Other fixtures --------------- •---•-••------•---•-----•---- <11 Design Flow.......... .......................gallons per person per day. Total daily flow........*..................................gallons. WSeptic Tank—Liquid capacity_��! _gallons Length___"._�.._.._._ Width_`!._."...___.. Diameter________________ Depth....`......... x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No._......_ ......... Diameter....... _/...... Depth below inlet............... Total leaching area.2 `?I....sq. ft. Z Other Distribution box (f) Dosing tank ( ) �jJ , `'' Percolation Test Results Performed by.�f......��"!`.��.r!!�':...`�.... ............. Date.g�:'�...�tO._�_,1-�� ,tea Test Pit No. 1. _��........minutes per inch Depth of Test Pit......e�____r--- Depth to ground water....�....._. fi Test Pit No. 2..1-Z_______minutes per inch Depth of Test Pit......_> ....... Depth to ground water........A16......... •-----------------------------------•---•-----------....----•---••----••••••••........-••••-••-•••••......................................................... ODescription of Soil........................................................................................................................................................................ U ••--•••.....-------•---...•-----•--�=/t�J....G'.�..... ..��...::��.!./G1_._...!.. C�/:, 1_V�L_--------------------------------------------------------------- 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 TITIL4 5 of the State Sanitary Code—The tAdersigned further agrees not to place the system in operation unt� ertificate o Compliance has bee board of health. .� e� g 6 Application Approved By.................................... ... ................ ..... _ 191 ... � ��at Date Application Disapproved for the following reaso . :---------•......................•--------------...-•---•---------•------------------------...----••-•••-••_._.. --------------------------------•-•-------------.......-----••---•---•---------------.......---------•--.._......--------....-•--------------.......-------------------------------------------------••- Date PermitNo......................................................... Issued-...................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......OF........... ..................... Trrtifiratr of T o mptiaurr THIS IS TO CERTIFY, That the Ind'vidu&ew,�ge Disposal System constructed �) or Repaired ( ) by.................................................... ................... ...... ....................................................... Installer i at ( vc .. taJ+�a2>_.. ..��. ------------------••-_. ......--•-•----•-•......••••. ------•-------------....------------•-•-- has been installed in accordance with the provisions of TIT F 5 of The State Sanitary Code es descrip in the application for Disposal Works Construction Permit No........... ._.__._____ dated._...........:. ` __. ...._...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FIJWION SATISFACTORY. DATE............... 3 t.2C` ............................. Inspector.......................... tS r ��J'I��THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ``]��`�� // o -• -•••....... No...•••••-----•_•.••..... FEE........................ - _ �i��n��1 n � � �trnrtuan rrntit �r� -----•---- •. . --- -- .•...•.....---------to-•••----- ....... Perm> saon > hereby granted__._._.:................ ..... '• to Construct ()e ) or Repair ( an Individual Se gage isposal Sy tem -{� v ---•• ..c:�2 ��'...-�-+•y I & ••-. � ..--•--•-••------- ............. Street D 6 - 6 z0 / Z �ta as shown on the application for Disposal Works Construction Permit No........... ........ Date -------------- ......................................... -I-.,.d. ..---------------......--•----•-- v DATE............ oard of Health ---- � a2S FORM 1255 A. M. SULKIN, INC., BOSTON F `rt ' r ! Cy .r- C, .�R,_A447.96 - ry si ....... 68.72 9 � NO rt EL� 4 1 o , � L 1 A . L. sa,od TOP OF.FOUNDATION CONCRETE COVER CONCRETE COVERS 4"CAST IRON 12"MAX. . ; OR SCHEDULE40 12"MAX. ^ P.V.C. PIPE '4"SCHEDULE 40 P.V.C.(ONLY) •• PITCH 1/4"PER.FT PIPE- MIN. LEACH e.� PITCH 1/4'P.ER.FT. PIT.. PRECAST o INVE e a LEACHING EL�:� •�• `-INVERT INVERT % . e•; PIT OR .'. SEPTIC TANK DIST. EQUIV. ,e INVERT ELv7!�. . .. BOX EL.�t ..�.: >x . :;� EL.y7 z.... lP.�.4.:..... CAL. INVER� �►_►' o ' •`� ELF. INVERT ww. ::t� 3/4°TO II/; WASHED ' . W STONE PROR LE OF IV GROUND WATER TABLE 38,, SEWAGE DISPOSAL SYSTEM E^�cov,vr�ird NO SCALE SOIL LOG WITNESSED BY : DATE .Ca ."�(v.' �... TIME... . . . . . . . . . . . . : BOARD OF HEALTH j TEST HOLE I TEST HOLE 2 (,� �Gl ., i1/G�/ 'l^.'*NGINEER oP 77 Pro 77M7 ems, •: U, /��. . �kcC'�9�l�lD�'�, $" Z' S� o�� DESIGN DATA : Z NUMBER OF BEDROOMS . . . Nled S4nd TOTAL ESTIMATED. FLOW .SJ . GALLONS/DAY BOTTOM LEACHING AREA . . SQ.FT./PIT SIDE LEACHING AREA . . �S/ . . . SO.FT./PIT GARBAGE DISPOSAL0 . . ..(50% AREA INCREASE) 3Z TOTAL LEACHING AREA SQ.FT PERCOLATION RATE AF 7,'' 'MIN/INCH LEACHING AREA PER PERCOLATION RATE .. SQ.FT. W&. :WATER ENCOUNTERED NUMBER OF LEACHING PITS . . . . . . . . . . . . . . . . 1 APPROVED . .. . . . . . . . . BOARD OF HEALTHto �'� �: . �IOJ ?. . . //3��?. . . . //3(!)•=.//�3 �,r�° l DATE. . . • .AGENTOR INSPECTOR ,. e� OF Mks e J. JACOBI 14 PETITIONER4: • • �, gNATAR;`?�. AYYLICATlo?: 1'OK L'LkCULH1'1V[v 7L'bl, �.:✓ LOCATION Z Z:L K NO. -sg.a3 VILLAGE Q DATE-.Al-,�Lo f APPLICAN FEE a TELEPHONE NO. (Non-refundable) ADDRESS ENG"INEER TELEPHONE NO. DATE'"SCHE ULED S� (Applicant's signature) _ ¢. ........o... . ..e- ......................... ASSESSOR'S�htAP�@ LOT NO: •�7�—/O� SOIL LOG SUB-DIVISION NAME DATE ��/(n�" o - TIME EXPANSION A EA: YES NO_ ENGINEER TOWN WATERPRIVATE WELL BOARD OF HEALTE OJ/t2+i�1� EXCAVATOR SKETCH: .(Street name,etc. ,dimensions of lot, exact location of test holes and percolation tests, locate wetlands in proximity to test holes) NOTES: )li 1 Q) 3 O` m � v b �Q, . 28 PERCOLATION RATE: �SS rHA/1l Z/n%/1�//1rG� TEST HOLE NO: ELEVATION: TEST HOLE NO: Z ELEVATION: I 1 �ToP CaAM 1 Tod/[o.airl �c,bSaiG 2Su[a��L 2 /YL' 3 3 4 4 5 fned 6 CDA/15C 6 (%A256 7 �t/7u W/ Savo 8 .e GeA��C. 9 9 KA IC-L 10 10 " 11 11 12 F 12 13 13 :. 14 .. 14 .. 15 15 16 16 SUITABLE FOR SUB-SURFACE SEWAGE: LEACHING FIELD- LEACHING PITS l� LEACHING TRENCHES_ UNSUITABLE FOR SUB-SURFACE.SEWAG.E. REASONS: NOT£: ENGINEERING PLANS MUST SHOW NUMBER ASSIGNED ON PERC TEST APPLICATION ORIdINAL: COMPLETED IN ENTIRETY -BY P. E. AND RETURNED TO BOARD OF HEALTH COPY: RETAINED BY APPIfICANT. '• ' ,