Loading...
HomeMy WebLinkAbout0005 CANTERBURY CIRCLE - Health 5,Canterbury Circle Hyannis P 249 112' l k f I I 1 TOWN OF BARNSTABLE LOCATION %5 C GlrA SEWAGE# Q611- a°l0 `,' LLAGE Nyl f ASSESSOR'S MAP&P CEL INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY d LEACHING FACILITY:.(type) CUP& (size) NO.OF BEDROOMS Al/�'OWNER I ��'� �• 62Y C PERMIT DATE: COMPLIANCE DATE: Q Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Fdcility 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 of leaching facility) Feet FURNISHED BY \ 0 r W 9J - Cl 0 r a o � w No. J !'U Fee At U THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: d.-_� Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS ZIpprication for Mir gar *pftem Congtruction i3ermit Application for a Perrut to Construct( )Re air(/)Upgra e Abandon ❑Complete System ❑Individual Components Location Address or Lot No.J 0 AAMe ur �1 1 Owner's Name,Address and Tel.No. Assessor's Map/Parcel H�/lV1n�S + �� rs !! �.y r a- 0'!�1 cvl. ( Q TS eve IAL Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms .N 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 N gallons. Plan Date !!! Number of sheets Revision Date Title Size of Septic Tank ' Type of S.A.S. Description of Soil: Nature of Repairs or Alterations(Answer when applicable) CtQlAa, IJ' 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 un it a ertifi- cate of Compliance has been issA by this Bo o Health. Signed ( Mq Date Application Approved by Date a l/ Application Disapproved f the following reasons Permit No. 0 Date Issued 2 l/ �. . �...�. ... .� .,- i-` '� � _� r n .- i - .- „•':L-..� -a.wa:- _ «marl_ .!..< No. ! — U 1 Fee AU v THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: .�, Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 01 tltlfication for iq gaf �pgt m �Con5truction Permit - -- Application'for a Permit to Construct( )Repai�( , )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components 1 Location Address or Lot No. ` Owner's Name,Address and Tel.No. S CAAT&r-6vry Cl r Assessor's Map/Parcel I NygnA,s , rVl Diu Aa+ /M I/LL - Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. -,Type of Building: / Dwelling No.of Bedrooms NI✓� Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow I,� gallons per day. Calculated daily flow NIL gallons. Plan Date Number sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil; Nature of Repairs or Alterations(Answer when applicable) (�Z 0A CeQ Date last inspected: Agreement: h ,/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 iss 4 by this Bo"Health. + . t Signed Date . -S' I I Applicarion Approved by Date ? / jApplicatron Disapproved f the following reasons Permit No. a°�� -a�llJ Date Issued Ph A --------------------------`---.---------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CE TIF)(/, that the On-site Sewage Disposal System Constructed( )Repaired ( )Upgraded ( ) Abandoned( )by /Ul un 4 u ✓1 at S C A tt' U l ci: Aa n\S has been constructed in accordance with the provisions o Title 5 and the for Disposal System Construction Permit No. !2-a I l - ° dated P- Installer R Designer n The issuance of this pe 't shall not e construed as a guarantee that the stem.it function as esighed. Date Inspector ,h r --------------------------------------- No. ? 0.1 I g Fee tiro THE COMMONWEALTH OF MASSACHUSETTS _ PUBLIC HEALTH DIVISION - BARNSTABLE} MASSACHUSETTS Mi5po.5ar *p,5tem Construction Permit Permission is hereby granted to Construct( )Repair(/)Up rade( )Abandon( ) ` System located at CAnT',A F` (-��AMI S and;,,A-ddscribed in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to com-bN with Title 5 and the following local provisions or special conditions. ovidedi.Construction/must be completed within three years of the date of th pe Date:_ 2 !_! _ Approved by � ti `,. Commonwealth of Massachusetts Title 5 Official Inspection or Subsurface Sewage Disposal System Form Not for Voluntary Assessments 5 Canterbury Circle Property Address Meredith Waites Owner Owner's Name information is MA 02664 07/07/2011 reqWred for every —Hyannis page- Cityfrown 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 on the computer, use only the tab 1 Inspector: key to move your cursor-do not MARK WHITE use the return Name of Inspector key. A B CANCO Company Name VQ 350 MAIN ST-ROUTE 28 Company Address W YARMOUTH MA 02673 Cityfrown state Zip Code 508-775-282,0 S-13381 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 0 Fails Needs Further Evaluation by the Local Approving Authority ron za: 07/08/2011 Inspector's Signature Date 7-11 The system inspector shall submit a copy of this inspection report to the Approving AutDgrity (bard of Health or DEP)within 30 days of completing this inspection. If the system is a shared:syst6ffl 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 DER 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. tsns-09M Title 5 Official Inspection Form:Subsurface Swage Disposal System•P40 1 Of 19 T \ Commonwealth of Massachusetts Title 5 OfficialInspection Form -- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments - 5 Canterbury Circle Property Address Meredith Waites Owner Owner's Name — -- information is Hyannis MA 02664 07/07/2011 y required for every ---------------- _ _ - page. Cityrrown state Zip Code Date of inspection B. Certification (coat.) Inspection Summary: Check A,B,C,D or E!always complete all of Section D A) System Passes: © 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 16.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13) 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 D N ❑ ND(Explain below): tSins•09/08 Title 5 official inspection Form:Subsurface sewage Disposal system•Page 2 of 19 �6. Commonwealth of Massachusetts --- Title 5 Official Inspection For Subsurface Sewage Disposal System(Form -Not for Voluntary Assessments 5 Canterbury Circle _..,_...._ Property Address Meredith Waites -------.-----..__ . ---..__--._-- Owner owner's Name information is H annis MA 02664 07/07/20.11 required for every page. City/Town State Zip code pate of Inspection B. Certification (coot.) B) System Conditionally Passes(cunt.): ❑ 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): A ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y Cl 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 11 N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): tsins•09108 Title 5 Official inspection forth:Subsurface Sewage Disposal System•Page 3 of 19 Commonwealth of Massachusetts 'title 5 OfficialInspection r Subsurface Sewage Disposal System Form Not for Voluntary Assessments 'T _5 Canterbury Circle Property Address Meredith Waites Owner Owner's Name information is H annis MA 02664 07/07/2011 _ required for every - gnis ---- �`— page. Cityfrown State Zap Code 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 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 B. Certification (cont.) 2. System will fail unless the Board of Health (and Public dater Supplier, if any) i that the system is functioning in a manner that protects the public health, determines 9 Y 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. El The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria 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. t5ins-09= TRIe 5 Qficiat Inspection Form!Subsurface Sewage Disposal System-Page 4 of 19 c Commonwealth of Massachusetts ONO Title 5 OfficialInspection r Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Canterbury Circle Property Address Meredith Waiter _-_-- Owner Owner's Name information is Hyannis MA 02664 0_7/_07/_2011 required for every ---- page. City/Town State Zip Code Date of inspection 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 ❑ z 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 ❑ z Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'h day flow B. Certification (coat.) Yes No ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ p 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. ❑ 0 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. t6ins•6g/08 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 6 of 19 Commonweafth of Massachusetts IJ Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form Not for Voluntary Assessments 5 Canterbury Circle Property Address Meredith Waites ...... ---------- ----------------------- Owner JO�r;.s information is MA 02664 07107/2011 required every Hyannis page. City/town state Zip Code Date of Inspedion 0 Any portion of a cesspool or privy is less than 100 feet but greater than 60 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 0 nX the system is within 400 feet of a surface drinking water supply 0 Z the system is within 200 feet of a tributary to a surface drinking water supply 11 the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—IWPA)or a mapped Zone 11 of a public water supply well If you have answered'yes"to any question in Section E the system is considered a significant threat, or answered"yes"in Section D above the large system 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 C. Checklist Check if the following have been done.You must indicate"yes!'or"no"as to each of the following: Yes No 2 El Pumping information was provided by the owner, occupant, or Board of Health ❑ 19 Were any of the system components pumped out in the previous two weeks? ❑ 9 Has the system received normal flows in the previous two week period? 2 Have large volumes of water been introduced to the system recently or as part of ❑ this inspection? Title 5 official inspection Fom Subsurface Sewage DOOS&I SYMM-Page 6 Of 19 Commonwealth of Massachusetts Title 5 Official Inspection or Subsurface Sewage Disposal System Form d Not for Voluntary Assessments —5 CanterbuaCircle Property Address Meredith Wailes Owner Owner's Name information is MA 02664 07/0712011 Hv required for every annisn State Zip Code Date of Inspection page. 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, including 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? FX1 ❑ 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: 0 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): unknown Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): unknown D. System Information Description: Number of current residents: Does residence have a garbage grinder? []Yes0 No LrAm-09108 Title s oificiai inspection Form:Subsurface Sewage Disposal System•Page 7 of 19 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Canterbury Circle Property Address Meredith Waites _------___. owner owner's Name information is H annis MA 02664 07/07/2011 required for every _................. --- ------ - -....._ page. CityfTgwn State Zip Code Date of inspection is laundry on a separate sewage system?[if yes separate inspection required] ❑Yes No Laundry system inspected? ❑Yes ❑ No Seasonal use? ❑Yes C7 No Water meter readings, if available(last 2 years usage(gpd)): - Detail: r Sump pump? ❑Yes 91 No Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment: __....._.-.__-- Design flow(based on 310 CM 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 Cl No Water meter readings, if available: _-- ®. System Information (coat.) Last date of occupancy/use: Date Other(describe below): Tale 5 official Inspection Fort:Subsurface Sewage mvosal System•Page 8 of 19 t5ms•09/08 I ' Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -- 5 Canterbuy Circle Property Address Meredith Waiter - - Owner Owner's Name information is Hyannis MA 02664 07/07/2011 required for every - - - page Cityrrown State Zip Code Date of inspection General Information Pumping Records: d�-r��� f�Ae) 67 Source of information: Was system pumped as part of the inspection? QYes Z No if yes, volume pumped: gallons _ -^ How was quantity pumped determined? Reason for pumping: Type of System: n Septic tank, distribution box, soil absorption system ❑ 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): D. System Information (cons.) Approximate age of all llcomponents, date installed (if known)and source of information: Titie 5 officiai inspection form.Subsurface Sewage Disposal System•Pale 9 of 19 t5ins•09108 Commonwealth of Massachusetts pTitle 5 Official Inspec tion For Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 5 Canterbury,Circle Property Address Meredith Waites u, ; Owner owner's Name information is H MA 02664 07/07/2011 required for every Stale lap Code Date of Inspectionpage. CItylTown Were sewage odors detected when arriving at the site? ❑Yes ED No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: x ❑other(explain): cast iron CI 40 PVC ._........._. Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: feet _ Material of construction: 0 concrete ❑metal ❑fiberglass T ❑polyethylene ❑other(explain) If tank is metal, list age: yeas Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) OYes 0 No Dimensions: Sludge depth:D. Systems Information (cost.) retie 5 Official Inspection Form:Subsurface Sewage oi.vosai System•Page 10 of 19 25ins•09/08 t.� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 5 Canterbury Circle Property Address Meredith Waites Owner Owner's Name information is MA 02664 07/0712011 .......Hyannis ........... required for every page cityfrown state Zip Code Date of Inspection - Septic Tank(cont) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liqui levels/as Z related tp outl t invert, evidence of lea age, etc , 77 Grease Trap(locate on site plan): Depth below grade: feet Material of construction: 0 concrete C metal 13 fiberglass 11 polyethylene M 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 -title 5 offidai inspection Form:subsurface Sewage Disposal System•Page 11 Of 19 tsirls-09108 Commonwealth of Massachusetts Title Official Inspection Foy - Subsurface Sewage Disposal System Form Not for Voluntary Assessments 5 Canterbury Circle Property Address Meredith Waiter Owner Owner's Name information is Hyannis MA 02664 07/07/2011 required for every .- __-- - requi CrtylTown state Zip Code Date of inspection pageD. System information (cunt.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): right 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 rrdle s official Inspection Form:sumuriace Sewage Disposal System•Page 12 of 19 tsirts:•09108 . Commonwealth of Massachusetts Title 5 Official Inspection For Subsurface Sewage Disposal System form -Not for Voluntary Assessments 5 Canterbury Circle _ - Property Address _ Meredith Waiter Owner Owner's Name information is MA 0266�4 07/07/2011 required for every Hyannis --. — --- page. City/Town ,-- State Zip Code Date of Inspection D. System Information (cons.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): -- Sox is filled with roots and in poor shape Pump Chamber(locate on site plan): Pumps in working order: OYes ❑ No Alarms in working order: ❑Yes El No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title 5 offic al Inspection Form:Subsurface Sewage Disposal System•Page 13 of 19 25ins•09108 , \ Commonwealth of Massachusetts --- Title 5 Official Inspection For Subsurface Sewage Disposal System Form-Not for Voluntary Assessments A 5 Canterbury Circle _ -- Prop"Address Meredith Waiter Owner Owner's Name information is MA 02664 _ 07/07/2011 _. required for every Hyannis --___.,__ _... _ -w-- page. City/Town State Zip Code Date of Inspection D. System Information (cons.) Type: � ® leaching pits number:l ❑ 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.): Leach it is extremely root infested and dry Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert 7itie 5 Official Inspection Form:Subsurface Sewage MspOsal System•Page 14 of 19 Mns•09108 ' Commonwealth of Massachusetts - Title 5 Official Inspection or Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -- 5 Canterbury Circle - -- Property Address - _Meredith Waites Owner owner's Name information is H anrns MA 02664 07/07/2011 --------_-...-- required for every —_�- ---- _ __-_---- --__.._--- page. Citytrown state Zip Code Date of inspection Depth of solids layer - —� Depth of scum layer Dimensions of cesspool Materials of construction _..-_-- Indication of groundwater inflow Oyes D No 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.): TWO 5 Official Inspection Form:Suksurface Sewage Disposal System•Page 15 of 19 tsiris•09too ' Commonwealth of Massachusetts - - Title 5 OfficialInspection r - Subsurface Sewage Disposal System Form _Not for Voluntary Assessments — 5 Canterbury Circle Property Address (Meredith Wailes T_-- -_._._. -___ -----._.__...... Owner Owner's Name information is �annis MA 02664 07/07/2011 required for every — page Cityfrown state Zip code Date of inspection D. System Information (cost.) 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 f� drawing attached separately Title 5 Official Inspection Form!Subsurface Sewage Disposal System•Page 16 of 19 tsins 09/Q3 h� • Commonwealth of Massachusetts Title 5 Official Inspection r o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments _* _5 Canterbury Circle Property Address Meredith Wailes Owner Owner's Name information is Hyannis _ MA 02664 07/07/2011 required for every —._._.-. _--•------ Cttytfown State Zip Code Date of inspection page i D. system information (cont.) Site Exam: F3 Check Slope 0 Surface water t5ins•09/08 7ttle 6 Official Inspection Form.Subsurface Sewage Disposal system•Page 17 of 19 Commonwealth of Massachusetts Title 5 Official Inspection► Form 01 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 5 Canterbury Circle Property Address Meredith Waites Owner Owner's Name information is MA 02664 07/07/20-1-1 Hyannis required for every State Zip Code Date of Inspection Page 6tyr:ic­wn ---- Check cellar fQ Shallow wells Estimated depth to no ground water: 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, n Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: s 6— s' You must descri e how you established the high ground water elevation: 7d �C- Before filing this Inspection Report, please see Report Completeness Checklist on next page. E. Report Completeness Checklist Z Inspection Summary: A, B, C, D, or E checked z inspection Summary D(System Failure Criteria Applicable to All Systems)completed Title 5 OfWal Inspection Form:subsurface Sewage Disposal System-P890 18 of 19 t6ins•CW08 commonwealth of Massachuse4ts --- Title 5 Official Inspection Foy - - Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 5 Canterbu Circle -� Property Address Meredith Wailes Owner Owner's Name information is D cti MA 02664 07/07/2011 wired for every Hyannis � /Town —-�--- State Zip Code Date of inspeon page C ity ® System Information-Estimated depth to high groundwater z Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 OfWal Inspection Form.Subsuriwe Sewage Disposal SYstem•Page 19 of 19 t5ins•09M COMMONWEALTH OF MASSACHUSETTS a EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION i TITLE 5 ` OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 5 Canterbury Circle Hyannis,MA 02601 Owner's Name: Meredith Watts__ Owner's Address: Date of Inspection: July 25. 2011 Name of.Inspector: (Please Print)Janies M.Ford Company Name: James M. Ford Mailing Address:. P.O.Box 49 Osterville,MA 02655-0049 Telephone Number: (508) 862-9400 CERTIFICATION STATEMENT I certify that have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed.based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(31.0 CMR 15.000). The-system: Passes ✓ Conditionally Passes N epds.Further Evaluation by:the Local Approving Authority ails Inspector's Signature: Date: July 27. 2011 �R �E)The system inspector shall s it a copy of this inspection report to the Approving Authority(Board.of Health or � �EP)within 30 days of completing this inspection. If the system is a h p g p shared s stem or has t Y y s a design flow of 10,000 a - gpd or greater,the inspector and the system owner shall submit the report to.the appropriate regional`office of the . DEP.. TheGoriginal should be sent to the system owner and copies sent to the buyer,if applicable,and the approving C.Nthority. Tiotes and Comtnents *This report only.descriues conditions at the time of inspection and under the conditions of use at that p-- time: This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 hispeetion Form 6/15/2000 page 1 I Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 5 Canterbun Circle Hyannis,MA Owner: Meredith Watts Date of Inspection: July 25, 2011 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 i m. 310 CMR 1 .5 303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments- B. System Conditionally Passes: ✓ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined";please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indic ating that the tank is less than g s n 20 years old is mailable. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled oT uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s)are replaced obstruction is removed ✓ distribution box is leveled or replaced ND explain:' The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass,inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 y Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 5 Canterbun�Circle Hyannis MA Owner: Meredith Watts Date of.Inspection: July 25. 2011 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 saf ety and the environment: Cesspool or privy is.within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: The system has aseptic tank and soil absorption system.(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS.and the SAS is within a Zone 1 of a public.water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance **This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other 3 Page_4 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: .5 Canterbury Circle Hyannis,MA Owner: Meredith Watts Date of Inspection: July 25, 2011 D. System Failure Criteria applicable to all systems: You must indicate either"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%z day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5,ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what.will be necessary to correct the failure. E: Large System: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gp d .You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) Yes No the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply _ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA) or a mapped Zone 11`of a'public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes"in Section above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 4 Page 5 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: S Canterbury Circle Hyannis,MA Owner: Meredith Watts Date of Inspection: July 25. 2011 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 nonnal 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 maintenance of subsurface sewage disposal systems? proper The size and location of the Soil Absorption System(SAS).on the site has been determined based on: Yes No Existing information.. For example,a plan at the Board of Health: ✓ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)]. Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: S Canterbury Circle Hyannis,M.4 Owner: Meredith Tfatts Date of Inspection: July 25, 2011 RESIDENTIAL FLOW CONDITIONS I -Number of bedrooms(design): N/a Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Number of current residents: 0 - -: Does residence have a garbage grinder(yes or no): n/a Is laundry on a separate sewage system(yes or no): n/a [if yes separate inspection required] Laundry system inspected(yes or no): No Seasonal use(yes or no): No Water meter readings,if available(last 2 years usage(gpd)): Unavailable Sump Pump(yes or no): No Last date of occupancy: Unknown COMMERCIAL/INDUSTRIAL Type of establishment: . Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): J 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: Unavailable Was system pumped as part of the inspection(yes or no): No If yes,volume.pumped: -gallons--How was quantity pumped detennined? Reason for pumping: TYPE OF SYSTEM . ✓ Septic tank,distribution box,soil absorption system Single cesspool i Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight Tank Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known) and source of information: Date of installation -un/viown Were sewage odors detected when arriving at the site(yes or no): ' No 6 . Page 7 of 11 OFFICIAL INSPECTION FORM- NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 5 Canterbury Circle Hyannis,MA Owner: Meredith Watts Date of Inspection: JuN 25 2011 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction: cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting;evidence of leakage,etc.): SEPTIC TANK:_ ✓ (locate on site plan) Depth below grade: IV V. Material of construction: ✓ concrete _metal _fiberglass _polyethylene other(explain) If tank is metal list age:. Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate)' Dimensions: 1000 gal. Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 30" Scum thickness: 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: 10" How were dimensions determined: -Measuring stick Comments(on pumping recommendations,inlet acid outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.). . The tees were Present. The liquid level was even with the outlet invert There did not avUear to be any signs of leaka e. There are some roots inside the tank. The tank should by Punived and roots removed. GREASE TRAP:- None (locate on site plan) Depth below grade: Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: . Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,.structural integrity,liquid levels ' as related to outlet invert,evidence of leakage,etc.): 7 Page e 8 of 11 OFFI CIAL AL IN SPECTION PECT ION FORM -.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S Canterbur y Circle Hyannis MA Owner: Meredith Watts Date of Inspection: July 25..2011 TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate.on site plan) Depth below grade: Material of construction: —concrete _metal _fiberglass _polyethylene _other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: - Alarm in workingder es or (Y or no): Date of last pumping: Comments(condition of alarm and float switches,etc): y DISTRIBUTION BOX: ✓ (if present must be opened) (locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and.distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The D-Box was broken down and dirt and roots inside. Needs to be re laced. PUMP CHAMBER: ,None (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no) Continents(note condition of pump chamber;condition of pumps and appurtenances,etc.): ' . 8 Page 9 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 5 Canterbury Circle _ Hyannis.MA Owner: Meredith Watts Date.of Inspection: July 25, 2011 SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,.number: I cement block it agyroxiniatelE 5'w x 7't x 9'bt 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.): 77te cess ool was dry. 7h.ere did not a ear to be any Signs o ailure. CESSPOOLS: None (cesspool must be pumped as part of inspection).(locate on site plan). Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.): PRIVY: None (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 I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S Canterbury Circle Hyannis,MA Owner: - Meredith Yilatts Date of Inspection: July 25 2011 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: �k A a 113 Q o y o 3 y 3s 10 Page 11 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S Canterbury Circle Hyannis,MA Owner: Meredith Watts Date of Inspection: July 25, 2011 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 30 +/- 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 ofHealth-explain:_ Topographic and water contours mans Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: . _Using Barnstable topographic and water contours maps the maps were showing approximately 30' to ground water at this site. This report has been prepared only for the septic system and components described herein. This septic system has beev inspected and conditional passed as of the date of inspection..This report is not a warranty or,guarantee that the system will fctnctiort properly in the fiatire. There have been no warranlies or.guarantees,either expressed,written or•-implied, relating to the septic system, the inspection, this report and/or any components of the septic System which have not been located and inspected. s 11 �.j ' TOWN OF BARNSTABLE T OCATLON °�C14A�7-rA J6 v/°h of SEWAGE # VILLAGE /y y�Alf�`V.��{ ASSSESSOR'S MAP & LOT C INSTALLER'S NAME&PHONE NO. 4�C C g_/ )S, SEPTIC TANK CAPACITY R( t'-1L4 e e LEACHING FACILITY: (type) (size) NO.OF BEDROOMS BUILDER O OWNE /� -0v°Al PERMTTDATE: /0- / > .o a COMPLIANCE DATE: L D Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �, —C �, � �. � a �' T. ,. I TOWN OF BARNSTABLE t I.00AT.ION C�h-�-c -S,�o--�, C i v', SEWAGE #�Q VILLAGE I -i G f S ASSESSOR'S MAP & LOT&2 YP' ��2 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) 7 (size) NO.OF BEDROOMS �S BUILDER OR OWNER PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist . on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by ( � °r J Cal o M �� 20®2 —ly"12 Fee ��. / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Zippfication for Migozal 6p.5tem .Construction Permit Application for a Permit to Construct( . )Repair(t/�pgrade( )Abandon( ) ❑Complete System R�<dividual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 5-0�— Assessor's Map/Parcel 171�?I —/ r ILI_ s-C'�4a��e�v�P t/�.� #,J Installer's Name,Address,and Tel.No. �'Q�- )rV A 7-0 O Designer's Name,Address and Tel.No. T 1�1�6 A- -5 7— Type of Building: Dwelling No.of Bedrooms vS 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 Nature of Repairs or Alterations(Answer when applicable) Oe /1 CF 'lj,4/A, /-//tiF Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described qn-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 i ue by this B . oard of Healt Signed - Date Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued No.'2(t� 1 ' r :Fee *` THE COMMONWEAL 'H OF MASA" HUSETTS Entered in computer: � a �F Yes PUBLIC HEALTH DIVISION- TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppYication for �D gpogal *p.5tem Construction Permit Application for a Permit to Construct( )Repair(61-05opgrade( )Abandon( ) ❑Complete System Al rdidividual Components Location Address or Lot No. Owner''s Name,Address and Tel.No. „S4$'a�'a" j�j� r. Assessor's Map/Parcel " Z . " �^1��y,7-i� , Installer's Name,Address;,and Tel.No. �!� r�}' ��J Designer's Name,Address and Tel.No. 5-0 U/- Y�iP Type of Building: f Dwelling No.of Bedrooms vS 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 Nature of Repairs or Alterations(Answer when applicable) E At d CC .^411(- />�-r Date last inspected-.- Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described o -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 i ue by this Board of Healt ..,.--^' ,�. Signed Date Application Approved by ""' Date Application Disapproved for the following reasons F Permit No. Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certiffcate of Compliance THIS IS TO CERTIFY that the On-site Sewage Disposal System Constructed( )Repaired ( 4rUpgraded( ) Abandoned( )byi- 4 1-6 elIA/c O � "a So �/,!/�' 37- 44., at .S �'R A. lPQ wf,l- C has been constructed in accordance with the ions of Title 5 and the foe isposal System Construction Permit No. 2007 -V 7.2 dated i of /i d t Installer 1flR.-sa-.� ...- e .�.�- Designer The iss Xce of th}s permit shall not be construed as a guarantee that the systerrL will function as designed. Date �� 1 i �� Inspectors 4`_ ---------------------------_ __— No. Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS 1i5poe ar *pmem Construction Permit Permission is hereby granted to Construct( )Repair( `'')Upgrade( )Abandon( ) System located at V e Y rl e 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. y Provided:Construct must be completed within three years of the date of this ermit. Date: �/ d-,- Approved b TOWN OF BA.RNSTABLE LOCATION "-C,4/��� ie vle e t'e SEWAGE # VILLAGE y��U�,� ASSESSOR'S MAP & LOT 'A Vf �l1� -4,10r-1)7S INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) (size) A NO.-OF BEDROOMS BUILDER 0 OWNE ® j FERMI DATE: /®-// - a COMPLIANCE DATE: AQ Q Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist Feet within 300 feet of leaching facility) . Furnished by iR i P - 112 - ' TROY WILLIAMS L - ­7 SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) - 8m-1500 19 Hummel Drive / South Dennis, A 02660 / COMMONWEALTH OF MASSACHUSET'I'S EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Properts Address: 5 Canterbury Circle Hyannis, Owner's Name: AgnesL.aureretta "v Owner's Address: 5 Cantebury Circle Q Hyannis,MA 02601 Date of Inspection: August 14, 2001 Name of Inspector: Troy M.Williams RECEIVED Company Name: Troy Williams Septic Inspections Mailing Address: 19 Hummel Drive Telephone Number: South Dennis,MA 02660 AUG 2`2 2001 (508)385-1300 TOWN OF BARNSTABLE CERTIFICATION STATEMENT HEALTH DEPT. 1 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. 1 am a DEP appro%ed system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The sv­.ten -Z Passes Conditionall.v Passes Needs flrrther Evaluation by the Local Approving Authurn) Fails Inspector's Signature: Z.J Date: 8 //Y/c 1 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of I lealth or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.'The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments Although system meets the minimum requirements set forth by the Massachusetts Department of Environmental Protection,certification is not to be construed as a guarantee of future working condition of system,piping or components. This inspection represents the conditions of the system on the Date of Inspection noted above. •`•*This report only describes conditions at the time of inspection and under the conditions of use at that time. l his inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 pace I Page 2 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 5 Canterbury Circle Property Address: Hyannis,MA Owner: Agnes Lauretta Date of Inspection: August 14, 2001 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 CNIR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section n d to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by th oard of Health, will pass. Answers es. no or not determined(Y,N,ND) in the for the following stat ents. If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tan (whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failur is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approve y the Board of Health. •A metal septic tank will pass inspection if it is structurally so d, 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 o or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled o neven distribution box. System will pass inspection if(with approval of Board of Health): bro n pipe(s)are replaced o truction is removed distribution box is leveled or replaced ND explain: The system requ' ed pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(w' approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: . 2 Page 3 of 1 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 5 Canterbury Circle Hyannis,MA Owner: Agnes Lauretta Date of Inspection: August 14, 2001 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health ui order to determine if the system is failing to protect public health, safety or the environment. 1. System Hill pass unless Board of Health determines in accordance with 310 CMR 15 03(1)(b)that the system is not functioning in a manner which will protect public health,safety and a 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 s t marsh 2. System will fail unless the Board of Health (and Public Wa r Supplier, if any)determines that the system is functioning in a manner that protects the public he th,safety and environment: The system has a septic tank and soil absorption s tem (SAS)and the SAS is within 100 feet of a surface +ater supple or tributary to a surface water pply. _ The system has a septic tank and SAS an the SAS is within a Zone 1 of a public water supply. The system has a septic tank and S and the SAS is %%ithin 50 feet of a private eater supply well _ The system has.a septic an d SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Me od used to determine distance **This system passes if th ell water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile or is compounds indicates that the well is free from pollution from that facility and the presence of amm is nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are tggered.A copy of the analysis must be attached to this form. 3. Other: 3 r Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 5 Canterbury Circle Property Address: Hyannis,MA Agnes Lauretta Owner: August 14,2001 Date of Inspection: 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 c102E,.ed SAS or cesspool ✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogwsed SAS or cesspool AtLl 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 %:day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the SAS,cesspool or privy is below high ground water elevation. _ IvM Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _ 1,114 Any portion of a cesspool or privy is within a Zone 1 of a public well. _ v/,g Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ !�L9 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 eater quality analysis. (This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this forma /►o (YesfNo)The system fails. 1 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 sign flow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the crite 'a above) yes no the system is within 400 feet of a surface drinkin ater supply the system is within 200 feet of a tributary t surface drinking water supply the system is located in a nitrogen sen ive area(Interim Wellhead Protection Area—1WPA)or a mapped Zone 11 of a public water supply w If you have answered"yes"to any que 'on in Section E the system is considered a significant threat,or answered "yes"in Section D above the large s tem has failed. The owner or operator of any large system considered a significant threat under Section E r failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner sho d contact the appropriate regional office of the Department. 4 Page 5 of I I OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 5 Canterbury Circle Hyannis,MA Owner: Agnes Lauretta Date of Inspection: August 14, 2001 Check if the following have been done. You must indicate`yes"or"no"as to each of the following: Yes No information was provided by the owner. occupant. or Board of I Lal,l, 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? _ Alj/ r 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: Yes no Existing information. For example, a plan at the Board of Health. Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] 5 Page 6 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION 5 Canterbury Circle Property Address: Hyannis,MA Owner: Agnes Lauretta Date of inspection: August 14, 2001 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 1 10 gpd x#of bedrooms): �3-3 o Number of current residents: . I Does residence have a garbage grinder(yes or no): y�S Is laundry on a separate sewage system (yes or if yes separate inspection required] Laundry system inspected(yes or no): jviq Seasonal use: (yes or no): A10 Water meter readings, if available(last 2 years)tsage(gpd)): D D = /2�ou o /� , 9 - z s,o u u Sump pump(yes or no):Aio Last date of occupancy: -U �j . COMM ERCIAL/INDUSTRIA L Type of establishment. Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.):_ Grease trap present(yes or no): industrial waste holding tank present(yes or no):_ Non-sanitary waste discharged to the Title 5 system (ye r no): Water meter readings, if available: _ Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: J v� ^r r ,h Was system pumped as part of the inspection(yes or no): ,,,rL, If yes, volume pumped: gallons-- Mow was quantity pumped determined? Reason for pumping: TYKE OF SYSTEM ,/ Septic tank,distfibulien 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 allcomponents. date installed (if known)and source of information: J✓ S• n .. 1 'I� s wt y fog i I { (�!- 7 3 Were sewage odors detected when arriving at the site (yes or no): N° 6 Page 7 of 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 Canterbury Circle Hyannis, MA Owner: Agnes Lauretta Date of Inspection: August 14, 2001 BUILDING SEWER(locate on site plan) Depth belo�� grade: lfl + Materials of construction: cast iron _40 PVC Zother(explain): Di,tanc:, fion. pri%ate water supply well or suction line: N/i9 ' .Comments(on+ condition of joints,,venting, evidence of leakage,etc.): 1 I Flv,.A k tit,S V,j I<-,� c (--- 4 i ?2 -ii.- 1 •to— y Gu . �c Pw'�c ?t YtG ru ✓ �4t1 SEPTIC TANK: ,/(locate on site plan) Depth below grade: 1 ' Material of construction:_✓concrete_metal_fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): _(attach a copy of certificate) Dimensions: _ j 'X q"V .. /voy s c. !(-v . Sludge depth. 31, - Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: NC-A--i_ Distance from top of scum to top of outlet tee or baffle: wo - v� Distance from.bottom of scum to bottom of outlet tee or baffle: s Flow were dimensions determined: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): S.s //�� .6`�4d^i_'f�.—�S-�—F-�`� c..i .>f.'It L .�... �` >J..w.f.''.�_ '•� .-._�._—__. 1 i.!r_✓-� � �_..t_W... (.+D✓It: , �i o:-dcr. /��b c . D< v� �11 t_ k.�c. sLL c i.;«s _^• 'mac n tC L.J c.j nu/�' h hc.< J of p.� ...�. •ny T- �. � .T)✓N c. GREASE TRAP:_(locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_fiberglass polyet ene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee orX Distance from bottom of scum to bottom of outlDate of last pumping:Comments(on pumping recommendations,inletfle condition, structural integrity, liquid levels as related to outlet invert,evidence of leaka etc.): 7 Page 8 of 1 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 Canterbury Circle Hyannis, MA Owner: Agnes Lauretta Date of Inspection: August 14, 2001 TIGHT or HOLDING TANK: (tank must be pumpe/timeof tion)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberylene other(explain): Dimensions: Capacity: gallons Design Floe gallons/day . Alarm present(yes or no): Alarm level: Alarm in working or r(yes or no): Date of last pumping: Comments(condition of alarm and fl t switches, etc.): DISTRIBUTION BOX: (if present must be opened)(1 ate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to lets equal,any evidence of solids carryover, any evidence of leakage into or out of box,etc.): PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condit' of pumps and appurtenances,etc.): 8 Page 9 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 Canterbury Circle Hyannis, MA Owner: Agnes Lauretta Date of Inspection: August 14, 2001 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) If SAS not located explain why: leaching pits, number: I — 7 X S b o c k h1 , 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.): 74z ..t_ w. �� f �u ww � . U 9, I y vim+ �Y�o G.✓ cJl.�..1 � d y .R r.�.i 1 c. _ /.�:-�. �.- �o.-t:)<<....J h '/�r e. �(J°.) 'f u✓t/ ....�C ut '9G > I S K .f P v/.�.r-e..✓� -�e..- o:� ..v.. -^-�- a+� CESSPOOLS: (cesspool must beZolpection)(1 ate on site plan)-7C-!---- �,,;, _ y C.", 1 JI��r Number and configuration: Depth--top of li(luid to inlet invert. Depth of solids layer:Depth of scum laver: Dimensions ofcesspoolMaterials of construction: Indication of groundwater inflow'(yes oComments(note condition of soil,signsevel 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 f ' ure, 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) 5 Canterbury Circle Property Address: Hyannis,MA Agnes Lauretta Owner: August 14, 2001 Date of Inspection: 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. 6 you 3� 10 f Page I 1 of 1 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 5 Canterbury Circle Hyannis,MA Owner: Agnes Lauretta Date of Inspection: August 14,2001 SITE EXAM Slope ✓ Surface water Check cellar ✓ Shallow wells Estimated depth to ground water feet Adjusted high ground water elevation Jy--7 'feet Please indicate(check)all methods used to determine the high ground %pater 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: Z, z s You must describe how you established the high ground water elevation: J p r"A S1- ,Y )� /� �` E�z....l.� �f<. a h -A G �J W � � t/ o..'� J1 v✓ j c- c.✓u.-tv.,.. . ;S� I w[.L) 4. YV/L 1,-y r/I w < � c� v.... �. �..,.. .,., ✓; J .✓ ... / c� .--A !� Gray' I 11.3 • 11 No.. "A - ----111-t- ........................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........... — ..................OF...................... ....... Appliratiou for Bisposal Works Tomitrurtiou an it Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Sys �qn at: 6 K. .......... ....... .............. ................. ................................................... oca�io Lot N .. .........Y ocatio U­ ................... ..X�o, fill C Address Xn Addre:,s ............ ................. . .. .. ........ .. ...... CU I t1l Size Address 9 Type of Building &Va Lot...J. feet U Dwelling—No. of Bedrooms.............3 -Expansion Attic Garbage Grinder ( ) pa ., Other—Type of Building .....*..................*... No. of persons----... Showers Cafeteria ( ) A4Other fixtures .................................................. ------ ............................................. Design Flow...............4r—O..................gallons per person per day. Total daily flow....... .......................gallons. V 1:4 Septic Tank—Liquid rcapacity]4 ff.g.gallons Length................ Width........._..._._ Diameter._...-__...._... Depth._........._.... Disposal Trench—No................. d h.................... Total Length.................... Total leaching area .............sq. f t. ..kt Seepage Pit No. Diameter.--- Depth below inlet.................... Total leaching area"',.' -'Me.s . f t. A Other Distribution b Do ing tank 0-4 I-r— Percolation.Test Results Performed by.......................................................................... Date........................................ Test Pit No. I----------------minutes per inch Depth of Test Pit__._......_..._..... Depth to ground water....__._..._.___...-__.. GXq Test Pit No. 2................minutes per inch Depth of Test Pit............_.__.... Depth to ground water------------------------ ........... ----------- .. ................. . ............. ............................................................. 0 Description of Soil..................... ... . . . ............. ............................................................ U ........................................................................................................................................................................................................ W z ----------------------------------........... ......................................................................................................................................................... U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ ............................................................................................................................ ........................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code-The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bee issued by the board of health. PX-17 C. .1 Signed--- ... ... .......... Date ...........Application Approved By................................ ...................... ........ ... ...... . . ........................................ Date Application Disapproved for the following reasons:..--------------------- ......... ........ .... --------------------------------------------------- ...................................................I..................................................... ....................................................................... Date Permit No. S ed-...................................................... ........................................................ Date ———--------------------------------------------------- ---------- - -- No... Fizz............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ...................................OF......................................................................................... Aplifiration for 43isposal Marks (foustrudivit Prrutit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Sys at: f"za .................................................................... ....... ................................................................................................... Locationf Address or Lot No. ..... ............ .. ....... .............. . . ...... .................. 'e.�r'7 4) 9wner Address s. ...........................................4xq_1............ .............................. ........................... nst Address Type of Building Size Lot....L4.'�L ...Sq. feet IJ Dwelling—No. of Bedrooms... ..................ExpansionAttic Garbage Grinder W-1 04 Other—Type of Building ............................ No. of persons.........�' ......... Showers Cafeteria P4Other fix ............................................................................................... . ..................................... Design Flow................ ......1',�..................gallons per person per day. Total daily flow........5_ .......................gallons. WV! ............­ 1:4 Septic Tank—Liquid capacitylk-L14allons Length................ Width.............._. Diameter._.._........... Depth................ Disposal Trench No........... Widtot................... Total Length.................... Total leaching area...................sq. ft. A, Seepage Pit No_ Diameter.. Depth below inlet.................... Total leaching ft. Other Distribution box Dosing tank ( Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. I................minutes per inch Depth of Test Pit..........._..._.... Depth to ground water----__--__---..--_-__. Test Pit No. 2................minutes per inch Depth of Test Pit....._.............. Depth to ground water.............._......._. ...........Z, 1:................. ......................... I .......................................................... 0 Description of Soil.................... ................. ..................... I.. ... ....... ..................... .......................................... �4 U ........................i................................................................................................................................................................................ W ...................................................................................................... ................................................................................................. �i U Nature of Repairs or Alterations—Answer when applicable..._....................................... .................................................... .................................................................................. ..........e......................................................................................................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The-undersigned further agrees not to place the system in operation until a Certificate of Compliance has be4l'issued by the board of heath. ­7 4, . ......................... ......... ................Signed......... ... ...? Date Application Approved By................................. ..... ..... ........................................................ .........................I.............. I Date Application Disapproved for the following reasons:................................................................................................................ .............................................................................................................................. .......................................................................... Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..........................................OF........................................................:............................ Tertifirate of Toutphatta 6e, THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed O or Repaired by............ ---------------------------­ .....................­.............­............................................... at_ ................................................................................has been'ihstalled in accordance with the provisio s of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No..................... .. ... dated...... ... ............ ............ THE ISSUANCE OF THIS CERTIFICATE SMALL NOT BE CONS RUED AS A GUARANTEE THAT THE SYSTEM WILL FU 0 SATISFACTORY. �T' DATE................... . .... ... ... .................................. Inspector..—.---- ..................... ............................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No......................... ... ............. ...............OF..................................................................................... FED...A Disposaj, Marko 011,Ongtrurtion Permit Permissions hereby granted........... ................................................................................................................ to Construct or Re InIp'�u,?a Sewage D*s�sal System atNo............. ............... ......... ....... ........ .. .711/ . .I. . .. . . . .............. ...... . ... ..... . Street s s as shown on the application for Disposal Works Construction Per ........... Dated.. .......... ................................................................. ...... .......................... 7 Board of Health DATE.......!J,: .....uel.................. ................... FORA 1255 HOBBS & WARREN, INC.. PUBLISHERS