HomeMy WebLinkAbout0017 CANTERBURY CIRCLE - Health 17 Canterbury Circle
Hyannis P
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TOWN OF BAaRNSTABLE
LOCATION lei SEWAGE# �d S �!
VILLAGE IS ASSESSOR'Sq!M'AP&PARCEL
INSTALLER'S AME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY. (type) (size)
NO.OF BEDROOMS 3 n / "(3-
OWNER i .f/ '
PERMIT DATE: _ 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
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No. CiCJ 1 —0 OR Fe `
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer.
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZippYication for Disposal 6pstem Construrtion permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. 1 7 e, Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel r
61Z -
Install 's Name,Addre ,and Tel. o. Designer's Name,Address,and Tel.No.
Type of Buildinf.
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building 43 &-,4-�No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) �/9' gpd Design flow provided N/Q gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank inp 0 Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
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 rece the system in operation until a Certificate of
Compliance has been issued by this Board of ealth.
S, �'� Date /f—
ApplicationApproved by Date I Zei "-
Application Disapprove y Date
for the following reasons
Permit No. ��� -068 Date Issued W///y/!�:
No. !� 1 7 _0" f' tr Fe (
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer. Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
01ppl tation for Disposal �pstem �CConstrUrtlOtl permit
Application for a Permit to Construct( ) Repair( ) Upgrade( ) Abandon( ) ; ❑CompletetSstem [IIndividual Components
Location Address or Lot No. Owner's Name,Address,and Tel.No.
Assessor's Map/Parcel r I' -� �<4,
Installe 's Name,Addres ,and Tel.40. Designer's Name,Address,and Tel.No.
Type of Buildin .
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building 2�5(DIG.��No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.jrequired) Nit gpd Design flow provided NA r gpd �
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank (06 O Type of S.A.S.
1 i
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) J ,�
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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 p6ce the system in operation until a Certificate of
Compliance has been issued by this Board of Health.
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Date /f/ i
Application Approved by 41 Date
Application Disapprove y Date
for the following reasons
Permit No. 6610i Date Issued N111 Zola r
-----------------------------------------`------------------------------------------------------------------ ------- ---------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate Of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( f) Upgraded( )
Abandoned( )by 1 2 d <,j 5f A-C,
at 17 u.- has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit Nods-069 dated C/
Installer-fe. / S k-w Designer Z./
#bedrooms C Approved d A design-flow A ,�( ,�!L n gp d i .
The issuance of this permit shal not be'construed as a guarantee that the system willf function as designed,? [/ j i ✓ z L
Date !i ! Inspector
No. 06 /dc) of
Fee
I THE COMMONWEALTH OF MASSACHUSETTS
I PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal 6pstrm ConstrUPtion Permit
Permission is hereby granted to Construct( ) Repair Upgrade( ) Abandon( )
System located at �jl/J�F t�T3 tt(1•� c�c�_ �(�/fX�Nn1_1$
and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with
Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
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Date Approved by
_�i
Hazardous Materials Inventory Sheet Checklist
gl Date
_Physical Street Address-Check database to ensure it exists
Working Phone Number
Actual Amounts -( ie. gas being used to fuel machines, thinner to
clean brushes all count as hazardous materials)
Storage Information -location of storage, how long is storage for?
If none, note that.
Disposal Information -where and who? If none, note that.
14L� Applicant Signature - understand what is listed and noted
Staff Initial -any questions, know who to ask
Vehicle Washing/Rinsing? - provide a vehicle washing policy and
explain it - note that it was given
Attach the Business Certificate with your sign off and comments
**The inventory form should explain what the business consists of and the procedures
they are doing. Notes need to be left to explain what you discussed with them.
s
YOU WISH TO OPEN A► BUSINESS?
For Your Information: Business certificates (cost$40.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which
you must do by M.G.L.-it does not give you permission to operate.) Business Certificates are available at the Town Cleric's Office, 1"FL., 367
Main Street, Hyannis, MA 02601: (Town Hall)
DATE: 5���f�y Fill in please:
L� F P•v f' �s' P�l:'pjptal.a c ,{
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,itir� br t� APPLICANT'S YOUR NAME/S: ��-I l ��l> n v�R 2TI.ri 5
B gS(l ESS YOUR HOME ADDRESS:
q:pT.'�1�T'f14'�i 6 6 --6"( t
TELEPHONE # Home Telephone Number
• M�In"�lu�w ����Qa�
.sir•'. '.1 •i!K.:-'ll'y'i:�;n w?*'� M�T
NAME OF CORPORATION: 55 ,OP �/Yk 9 3 .2 - 9
NAME OF NEW BUSINESs C1�/ & r L.a iv 0 . C,q 1�/C TYPE OF BUSINESS L,�iv/� SCff/�h/C
IS THIS A HOME OCCUPATION? YES NO
ADDRESS OF BUSINESS �1- C ivT�ft Rv2 r !;�tx Lt}'Al-411 5, wt, MAP/PARCEL NUMBER (Assessing)
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of
Barnstable: This form is intended to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. - (corner of Yarmouth
Rd. &Main Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature*
COMMENTS:
2. BOARD OF HEALTH
er it re ments that attain to this type of business.
This individual h b n in r ed of the P
MUST COMPLY WITH ALL
Authorized ignature** H"00US MATERIALS REGULATIONS
COMMENTS:
3. CONSUMER AFFAIR L ENSING U HORITY)
This individual h s b en inform f th�fii�ensiing requirements that pertain.to this type of business.
Authorized gnature
COMMENTS:
TOWN OF BARNSTABLE Date-6
TOXIC AND HAZARDOUS MATERIALS
NAME OF BUSINESS: iy y �T L/ �yl�S��-1�1.vc �IZOW
BUSINESS LOCATION: 1-4- CAT(-/t zt/x N <-to t<+ t A,'v1v 0260` INVENTORY
MAILING ADDRESS: dX c F/vT C-fZ Iil L L G , a Z6 32 TOTAL AMOUNT:
TELEPHONE NUMBER: `-r f 4- 61 5-1
CONTACT PERSON: '600.s H(n :4- �q S"(
EMERGENCY CONTACT TELEPHONE NUMBER: G-/g )-® 0D41-,YMSDS ON SITE?
TYPE OF BUSINESS: L ms c^ pl c
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous waste:
Name of Hauler: Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous material use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The board of health and the Public Health Division have determined that the following products exhibit toxic or
hazardous characteristics and must be registered regardless of volume.
Observed / Maximum Observed / Maximum
Antifreeze (for gasoline or coolant systems) Miscellaneous Corrosive
❑ NEW ❑ USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
❑ NEW ❑ USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel,Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil ❑ NEW ❑ USED
Miscellaneous petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil ❑ NEW ❑ USED
Degreasers for engines and metal Printing ink
Degreasers for driveways&garages-_, Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Miscellaneous Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt& roofing tar PCB's
Paints, varnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (including carbon tetrachloride)
❑ NEW ❑ USED Any other products with "poison" labels
(including chloroform, formaldehyde,
Paint&varnish removers, deglossers hydrochloric acid, other acids)
Miscellaneous. Flammables Other products not listed which you feel
Floor&furniture strippers may bet xic or hazardous (please list):
Metal polishes Q
Laundry soil &stain removers
(including bleach)
Spot removers&cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT I CANARY COPY-BUSINESS Applicant's Signature Staff's Initials
M
Town of Barnstable Barn
Regulatory Services Department "' 'N
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KAM
639. Public Health Division �-
♦�
200 Main Street, Hyannis MA 02601 200�
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL#7014 1200 0001 0358 0375
February 17, 2015
Federal Home Loan Mortgage Corp.
8200 Jones Branch Drive
McLean Va 22102-3110
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 17 Canterbury Circle, Hyannis, MA was last
inspected on 1111/2015, by Trevor Kellett, a certified septic inspector for the
State of Massachusetts.
The inspection of the septic system showed that the system "Conditionally
Passes".under the guidelines of the 1995 TITLE 5 (310 CMR 15.00) due to the
following:
• Distribution-Box needs to be replaced.
C Need to replace 1500 gallon septic tank-
along with piping.
I
You are ordered to repair or replace the septic system within sixty (60) days
from the date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in
future enforcement action.
PER ORDER OF THE BOARD OF HEALTH
i
om s McKean, R.S. CHO
Agent of the Board of Health
Q:\SEPTIC\Conditionally Passes Ltr\17 Canterbury Circle,Hy Feb 20i5.doc
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• Parcel Info -}
Parcel ID 249.111 Developer Lot LIDT6
Location 17 CANTERBURY CIRCL Pri Frontage 120
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village HYANNIS Fire District HYANNIS
Town sewer exists atthis address No Road Index '0224 _
Asbuilt Septic Scan; '
249111 1 Interactive Map
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owner FEDERAL HOME LOAN I Co-
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Computer name : HEALTH899JF User name : flvnni Operatinq Svstem : Windows NT(5.1)
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�. 17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is
required for every Hyannis MA 02601 1.11.15
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When filling out forma A. General Information
on the computer, I I
use only the tab 1. Inspector.-
key to move your
cursor-do not Trevor Kellett
use the return Name of Inspector
key. `t.
TK Septic Inspections
Company Name
38 Vacation Lane i
Company Address
/!V West Yarmouth MA 02673
City/Town State Zip Code
508-579-5502 S 113744
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
1.12.15
Inspectors Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 1 of 17
c
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is
required for every Hyannis MA 02601 1.11.15
page. City/Town 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:
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):
The septic tanks tees are not in good shape, the tank it self seems to be holding water
t5ins•3/13 Title 5 Offldal Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is
required for every Hyannis MA 02601 1.11.15
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 istatic 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 d box is not structurally sound should be repaired or replaced
❑ 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.
j 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 Me 5 Olfidal Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner owner's Name
information is
required for every Hyannis MA 02601 1.11.15
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 to-ik 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/day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form }
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner owner's Name
information is required for every Hyannis MA 02601 1.11.15
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
❑ El Area
system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
a
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.
15ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
:i
w 17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is
required for every Hyannis MA 02601 1.11.15
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
❑ ® Pumping ir:formation 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): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CIV.R 15.203(for example: 110 gpd x#of bedrooms): 330
t51ns•3/13 Title 5 Official Inspedon Form:Subsurface Sewage Disposal System•Page 6 of 17
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
9 P y ►Y
w 17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is
required for every Hyannis MA 02601 1.11.15
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available(last 2 years usage(gpd)):
Detail.-
Sump pump? ❑ Yes ® No
Last date of occupancy: 2014
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•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
�r
w 17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is required for every Hyannis MA 02601 1.11.15
_
page. City/Town State Zip Code Date of Inspection
D. System Information (coot.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no)(if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for.Voluntary Assessments
w 17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is required for every Hyannis MA 02601 1.11.15
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:
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.1
feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: '8
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
• years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000g
Sludge depth: T
t5ins•3113 - Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is required for every Hyannis MA 02601 1.11.15
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
24"
Scum thickness
2"
Distance from top of scum to top of outlet tee or baffle
4"
Distance from bottom of scum to bottom of outlet tee or baffle 16
How were dimensions determined? measured
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Septic tank is structurally sound and water tight with liquid at the outlet invert,the water sits a little
higher than invert seems to be a pitch problem since can pass through, tees need repair/replacement
as stated above
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•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form l
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is
required for every Hyannis MA 02601 1.11.15
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
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is
required for every Hyannis MA 02601 1.11.15
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 water below 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.):
D Box is level and covered to the top in scum, and crumbling in need of replacement
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in workingorder: *
❑ Yes ❑ No
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System(SAS)(locate on site plan, excavation not required):
If SAS not located, explain why:
Mrs•3/13 Title 5 Official Inspection Form:Subsurface Sewage Dlsposel System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
1, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w 17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is
required for every Hyannis MA 02601 1.11.15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: 4
❑ 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.):
The leaching at the this property consists of 4 infiltrators there was no sign of staining or ponding in
the leaching stones
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
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is required for every Hyannis MA 02601 1.11.15
page. City/Town 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official -Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is required for every Hyannis MA 02601 1.11.15
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
B
A
Outlet end ❑
cover is a
6"x12" block
Inspection Hole
2
O ent
A1)18
A2)21.5
A3)31.5
B1)61.5
B2)63.5
B3)54.5
Inspection Hole
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
w 17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is
required for every Hyannis MA 02601 1.11.15
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: 50+
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:
USGS Maps show GW at 50 feet
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Forth: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
17 Canterbury Circle
Property Address
MARCONDES, MAICO
Owner Owner's Name
information is required for every Hyannis MA 02601 1.11.15
page. City/Town 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
Mrs-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 17 of 17
COMMONWEALTH OF MASSACHUSETI'S
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
MAR 2 9 2005
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLES.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SIEWACE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
.AP
14-9
Property Address:' ? t /i.✓J t 2��r�21' Gr ,2 G% �,t�(: t
l �
• Owner's Name:
Owner's Address: i-7 zAY
Date ofTnspection: M A jL Lhr 4;L/ �►°
Name of Inspector.(please print)Urg%,/t
Company Name:
Mailing Address: ,3a x -5 �5/
Telephone Number-
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection.The inspection was.performed based on my
training and experience in the proper fimction and maintenance of on site sewage disposal systems.I am a DEP
approved system inspector pursuant to Section 15-W of Title 5(310 CMRIS.000). The system:
Passes
Conditionally Passes
Nerds Further Evaluation by the Local Approving Authority
Fails
Inspee#orTs Sagnatu Date:
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Healh or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments -
****This report only descn'bes conditions at the time of.inspection and under the conditions of use at that
time.This inspectiom does not address how the system will perform in the.future under the same or different
conditions of use.
I
Page 2 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESS
SUBSUUACE SEW.AOEDEPOSAL.SYSTEMINNSPMMON FORM
PART A
CERTIFICATION(conned)
Property Address:% �i9 y i E
,y, ,ly orvn/rS
Owner/'/� 'Lc s e •-1 .q-5
Date of Inspection: p
Inspection Summary: Check AAC,D or E fALVVAYS Complete anof'Secfwx D-
A. Syste
i have not found any information which md=es that any of the failure criteria described in 310 CNtit
�303 or in 31fl CMR I5_304 exist Anyuure criteria not evaluated are indicated below_
Comments:
B. 'System Conditionally Passes:
One or more system componems as described in the"Conditional Pass"section need to be replaced or
repaired_The system,upon completion of the replacemem-orrepair,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 tauk.failove i lmninmr System will pass.inspecsioat i€he
existmg tank is replaced with a complying septic tank as approved by the Bind.ofHealth.
*A metal septic-tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compiiartm
indicating-that the tank is less than 20 years old is available_
ND explain:
Ooservation of sewage backup or break ouutcrhigh- tatic watur.level in t1adistrxbunion.hnx.due to broken or,
obstructed pipe(s)or.due to a broken,settled orx nevcn distribution.box.System will pass.inspecEion if(with
approval of Board of Health):
broken pipe(s}are replaced
obstruction is removed
disEnbuutiion box is .or replaced .
ND explain:
The system required pumping more than 4 times a year due to.broken.ot obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
rtD explain:
Page 3 of 11
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A '
CERTIFICATION(continued) .
Property Address:
Owner. �lAfe ✓2 —/�S
Date of Inspection:
C. Further Evaluation is Required by the Board of Health: -
Conditions exist which require further eval on by the Board of Health in order to determine if the system
is failing to protect public health,safety or nment_
1
1. System will unless Board Health determines in accordance with 310 CMR 15.303(i)(b)that the
system is IIOt fiin a I manner which will protect public h
\ n P P nth,safety and the environment:
Cesspool or vy" 50 feet of a surface water
— Cesspool or priv�is within feet of a bordering vegetated wetland or a salt marsh
J
2. System will fail unless the Board of H th,(a ablic Water Supplier,if any)determines that the
system is functioning in a manner that p e blic health,safety and environment:
_ The system has a septic tank an soil on system(SAS)and the SAS is within 100 feet of a
suface water supply or tributary to a water supply.
_ The system has a septic tank AS and the SAS is within a Zone I of a public water supply_
_ The system a sep a SAS and the SAS is within 50 feet of a private water supply well.
f .
_ The system has a s c and SAS and the SAS is less than 100 feet but 50 feet or more frona a
private water supply == thod used to determine distance
"This s if th ell water analysis,performed at a DEP certified laboratory,for coliform
bacteria and v 1 'e o c compounds indicates that the well is free from pollution from that facility and
the presence of nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no ether
fail=criteria a trigb .A copy of the analysis must be attached to this form_
3. Other.
Page 4 of l I
OMCIAL INSPECTTON:FORM—NOT FOR VOLUNTARY ASSESSMENT'S
SUBSURFACE SEWAGE DISPOSAL-SYSTEMINSPEC"MN FORM
PART A
CERTIMATION(coutinuedy
Property Address: /, V 7,e
-a Y/-9 v�v%_5
Owner:/19.e q, 9 s
Date of Inspection: , — �Z4
D. System Failure Criteria applicable to all systems.
You mast indicate"fires"or"no"to each of the following for all inspections:
Yes No
— aclkap of sewage into facility or system component due to overloaded or clogged SAS or cesspool
— 7-Discharge or ponding of effluent to the surface of the groimd or smfacewaters due to an overloadzd or
_,c4ogged SAS or cesspool
Static liquid level in the distribution box above outlet invert duueto arroverloaded or clogged SAS or
oI
grid depth in cesspool is less than 6' below invert or-available-volume is less than%Z day flow
Repaired pumping more than 4 times in the last yearNOT due to clo or obstructed i s-Number
�f times pumped
� P Pe( )
-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 ofa public well.
Any portion of a cesspool or privy is within 50 feet of a private water supphr:well.
Any portion ofa cesspool or privy is-lesstharr 100 feet but greater than 50 feet from a private water
supply well with no acceptable waterqualityanalysis.[This system passes if the well water analysis,
performed at a IDEP 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�8an eq thaftS FPm,provided-first no other faalnse criteria
are triggered.A copy of the analysismust be attachea.Mthis brim l
l G/ (Yes/No)The system faits 1-have determined_that one or mare ofrhe above fainge..rdteria erast as
described in 310 aM 15.303,theref a-the-system fsils•The system mAner.stranld contact the Board of
Health to deternime what-will be-nece ary to correct the failure.
E. Marge Systems: l
To be considered a large system the system assfs rt afacfiity.wiffi$.des1pMow of 10,000 gpd to-15,300
aPd- `t
Yon roust indicate or"no"tb each of llowing:
(The following criteria Iy uge. stems i n to the criteria above)
yes no
— — the system is 400 feet o surface drinl®g water supply
_ A
— the system is 200� of a-tributary to a surface.drinking water,supply
the system is 1 a nitrogen sensitive m ea(Interim Wellhead Protection Area—MTA)or a ripped
Zone R ofa pu 'c 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.filed.Th=.owner or open=of any large system considered a
Significant threat under-Section E or failed under Section D shall upgrade the system in accordance with 3 10 CNIR
15304.The system owner should contact the appropriate regional office of the Department.
Y "Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:/ ( F) %s!�5 j2�r► 112 �_�'
Owner./7)n, [15
T
u
Date of Inspection• 3
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
/W ere any of the system components pumped out in the previous two weeks
Z— Has the system received normal flows in the previous two week period?
— -Z Have large volumes of water been introduced to the system recently or as part of this inspection?
Were as built plans of the m 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 ect— inspected for signs
.— uup gas of break out .
ZWere 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?
i,
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:
Y�o0
Existing information.For example,a.p at the Board of Health
_ _ Determined in the field(if any of the fail related in Part C is at issue approximation of distance
is unacceptable)P 10 CMR 15.302(3)(b)]
p
Page 6 of l l
q
OFFICIAL`INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE I1SPOSAL-SY'STEMTNSPEf.0W FORM
RART-C
SYSTEM EVORMATION
Property Addrr.4 C A.✓r"e
JIVAli .S
Date of Inspection:
FLOW CONDMONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedmbms(actual)
DESIGN flow based on 310 CMR L5.203(for example-110 gpd x 4-oTa&omsj 3 .3
Number of current residents:_�11
Does residence have a garbage grinder(yes or no)!X/d
Is laundry on a separate sewage system_{M or no):A/ (if yes separate-inspection required]
Laundry system inspected(ye;or no):N
Seasonal use:(yes or no) -IV
Water meter readings,if a 'able(last 2 years usa (gpd)):
Sump pump(yes or no):
Last date of occupancy:-��'
COMMERCTALIMUSTRIAL
Type of establishment
Design flow(b on 3I0 C 15.203): epd
Basis of design o seats/ ons/sgft,etc.): ,
Grease trap present ono):
Industrial waste bold' present(yes or no):_
Non-sani w tart' rite bed to the Title 5 stem es or no
system(y )
Water meter rea " o able:
Last date of occupancy/use:
OTHER(describe):
GENEXAL IN UVUnON
Pumping Records
Source ofuiformation: -
VTas system pumped-as part ofthe inspection(yes orno):_2j
If yes,volume pumped`__gallons--How-was quantity.pmnped'deflermmed?_
Reason for pumping:
TYPTf
OF5 YS'PElg1[-
Seeptic tank,disuzbution box,soil absorption system .
_Single-cesspool --
Overflow-cesspool
Irrivy
_Shared system-(yes or-no)(if yes,aita ds,if an
Innovative/Ahernativetechnology.Attachxciopy ofihe current operation and maintenance-contract(to be
obtained-from system owner)
_Tight tank _Attach a copy of the DEP approval
—Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Were sewage odors detected when arriving at the site(yes or no):AZ
P;tge 7 of I I
QMCLA-L INSPELMON.FORM—NOT FOR VOLUNTARY ASSESSWNTS
SUBSURFACE SEWAGE DISPOSAL-SYSTEM INSPECTION FORM
PAIN'C
SYSTEM INFORMATION(continued)
Property Address:/7 64NTE
Owner.
Date of Insp tfim � -o
BUILDING SEWER(locate on site plan)
Depth below grade: !�
Materials of construction: cast iron Z4'0�PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.).
SUTIC TAN''X:IS/,,_(locate on site plan)
Depth below grade:
Material of construction: onca ere metal fiberglass_polyethylene
1f Milk is metal list age:_ Is age confirmed by a Certificate of Compliance es .
certificate) mP (D' or no) _(at�ch a copy c
/
Dimensions:
Sludge depth:,3,'
Distance from top of sludge to bottom of outlet tee or baffle:3
Sctm thickness: - '� �
Distance from top of scum to top of oudettee or baffle: 5l
Distance from bottom of scum to bottom of outlet tee or bale:
How were dimensions determined: /'!r"!�S�,�j' � 5� �
Comments(on Pumping recommendation,inlet and tlet tee or bafle condition structural
as related to outlet in y integrity,liquid]r:=ls
.� invert of. etc.): .
✓3 �f tJ '
G REASE TRAP: (locate on site plan) 1
Depth below grade:
Material of eonstrttction:— metal fiberrolass_polyethylene other
{e�Iam):
Dimensions:
Scl m thickness:
Distance from top of sc. top of outlet tee or bale:
Distance from bottom of to bottom of outlet tee or bale:
Date of last pumping:
Comments(on pump endaQions,inlet and outlet tee or bale condition,structural integrity,liquid lev—Js
as related to outlet in ert,evidence of leakage,etc.):
Page 9 of 11
OMCUL INS ON FORM—NOT
-SEWAGE DISPOSAL Slhi�'S
OBSUWACE FOR VOLUNTARY ASS
PARS,C �QN FORM.-
D�i .
Pmpertry dress: l7C
®wnQr:z
A2 c c , �� T9.s
Date of
G ^T or l OL) NG Tom:
tta�''mnst be d=�dme of- on site Depth below grade: P )
Material of n c
metal fiberglass_lm }''.
Dimensions: °&:r(exPlk _
Capacity.
Design Flons
ow /.
jamgaiIonslday
P�'�sent or no
Akarm level: in�� dg.arer
Date oflast pia (Yes orno):
Comm ' —
condition of alarm.and float switches,etc.):
D�LkTI�3T�I Sri:
C�present rarest be opened)(locate on site plan)
Depth of liquid level above owlet invert; _��
Comment(note if box is level and distn-�on to outlets
3- P into or out of �'ay evidence of solids
r�" S) �vez,my eWd=F-of
--------------
FUMP (locate site plan)
PUMPS in worms (yes or o)-
Alarms in working oiler r no)
Ccmine•"ote coition plimP chamber vwonofva&psttd ,emJ_
� I
i Page 9 of I 1
OFFICIAI.INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property.Address:_ :? 6 4)%14r—
y� ti �
Owner.//fin c .)- e� 5"
Date of InspectionS'—
SOIL ABSORPTION SYSTEM(SAS): (locate on siteplan,excavation not required)
If SAS not located explain why.
Type
1 Ching pits,number._
i leaching chambers,number
leachi WpHeries,number.
leaching trenches,number,length:
leachin-fields,umber;dimensions:
overflawcesspool,number_
irmovative/ahernative system-Type/name of technology:
Comments(note"condition-ofsoil,-signs of hydraulic*Qmr,level ofpondmg,damp soil,condition of vegetation,
etc. :
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and •nfiguration:
Depth—top o 'quid to" et invert
Depth of solids ayer.
Depth of scum I r
Dimensions of ce ool:
Materials of co on:
Indication of groun r infiow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc_):
i
PRIVY: (lo on site an).
Materials of constructs n:
Dimensions:
Depth of solids:
Comments(note co on
soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPEMON FORM—NOT FOR VOLUNTARY ASSESSMF,NTS
SUBSURFACE SEWAGE-iDISPOSALSY EEM DMEMON FORM
PART.E
SYSTEWINFORMATION(cxntim�
Property Address _ q�z t2 A %
_�y,q IV 41 o S
Date of Inspection: .
SKETCH OF SEWAGE DISPOSAL SYSTEM--
Provide a sketch of the sewage disposal system includingties to ar'se�--tiwo-pe c,—tt-reference I
benchmarlm Locate alrweils within'100 feet Locate where-public watm supply-enters the-built in&
e/
Li
-
G
- t
------------
��Q-
Pose 11 of I
OMCAL D SPECnON FORM-NOT FOR VODU "PARRY ASSESSMENTS
SuBsuRFAcE SEW-AGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM FORMATION(co�iaued).
a-ope;ty Address:%7C ,V*7.� .�,e,
_ Y-A v V.,j
L'mmei:�!/l� G L S
Late of inspecHou:
SITE EXAM
Slc=
Sur;ace water
Ch=k cellar
Shaiiow wells
i
Estimated depth to ground water�O feet
Please indicate(check)all methods used to determine the high grotmd water elevation:
Obtained from system design plans on record-If check.,date of design plan reviewed:
Observed site(abutting property/observation hole within ISO feet of SAS)
Cheesed with Ioczl Board ofHeaWi-explain:
Checked with local excavators,installers-(attach documentation)
Acansed USGS database-explain:
You must describe how you established the-hLah ground wF#er elevation:
Q 1 -
1
Mar , ll . 2005 .-2:59PM No-1524 P 12
ixNgb I 1 of I I
F '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SFWArE DISPOSAL SYSTEM INSP .CTiON FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 CANTERBERRY CIRCLE HYANNI 02601
Owner: ANN ECENZALLI
Dnte or Inspection: 1/ m
sin EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
FMimated depth to ground water 10+feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from systenn design plans on record-If checked,date of design plan reviewed:n/a
YES Observed site:(abutting property/observation hole within ISO feet of SAS)
NO Checked with local Board of Health-explain:n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 10+FT.
c
t .
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
i
F
m
d
OW
COP?
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM -----.
PART A R"= I V E D
CERTIFICATION
JAN 2 9 2003
Property Address: 17 CANTERBERRY CIRCLE HYANNI 02601
Owner's Name: ANN ECENZALLI TOWN OF BARNSTASLE
Owner's Address: 17 CANTERBERRY CIRCLE HYANNI 02601
HEALTH U EPT.
Date of Inspection: 1/3/03
Name of Inspector: (please print) JOHN GRACI 20-9
Company Name: SEPTIC INSPECTIONS e( , lC— MAP
Mailing Address: P.O. BOX 2119 TEATICKET, MA.02536 PARCEL. �_.,.:.:..1..._..
Telephone Number: 508-564-6813 FAX 508-564-7270 LOT - -
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
X Passes
_ Conditionally P sses
_ Needs Furth jr 'valuation by the Local Approving Authority
Fails
Date: 1/3/03
Inspector's Signature: -. /
The system inspector shall submit copy of this inspection report to the Approving Authority(Board of Health or DEP)within
30 days of completing this inspect on. If the system is a she
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 thesystem owner and copies sent to the buyer, if applicable, and the approving authority.
Notes and Comments
THE SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
****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.
Page 2 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 17 CANTERBERRY CIRCLE HYANNI 02601
Owner: ANN ECENZALLI
Date of Inspection: 1/3/03
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG
THE SYSTEM'S USEFUL LIFE.
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.
n/a The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old is available.
ND explain: n/a
n/a Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed
pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a 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: n/a
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 17 CANTERBERRY CIRCLE HYANNI 02601
Owner: ANN ECENZALLI
Date of Inspection: 1/3/03
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to
protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is
not functioning in a manner which will protect public health,safety and the environment:
_ Cesspool or privy is within 50 feet of a surface water
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water
supply or tributary to a surface water supply.
_ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water
supply well". Method used to determine distance n/a
"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:
n/a
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 17 CANTERBERRY CIRCLE HYANNI 02601
Owner: ANN ECENZALLI
Date of Inspection: 1/3/03
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for alLinspections:
Yes No
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z day flow
_ X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
_ X Any portion of the SAS, cesspool or privy is below high ground water elevation.
X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone 1 of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.]
_ (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X 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.
a
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 17 CANTERBERRY CIRCLE HYANNI 02601
Owner: ANN ECENZALLI
Date of Inspection: 1/3/03
Check if the following have been done.You must indicate "yes"or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period?
_ X Have large volumes of water been introduced to the system recently or as part of this inspection ?
X _ Were as built plans of the system obtained and examined? If the were not available note as N/A
P Y ( Y )
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS,located on site?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees material of construction dimensions depth of liquid,depth of sludge and depth of scum?
i
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example,a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable) [310 CMR 15.302(3)(b)]
5
f
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 17 CANTERBERRY CIRCLE HYANNI 02601
Owner: ANN ECENZALLI
Date of Inspection: 113103
FLOW CONDITIONS
RESIDENTIAL
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
Number of current residents: I
Does residence have a garbage grinder(yes or no): YES
Is laundry on a separate sewage system(yes or no): NO [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)): n/a
Sump pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings,if available: n/a
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes, attach previous inspection records, if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
2000 PERMIT#2000- 196
Were sewage odors detected when arriving at the site(yes or no): NO
F
Page 7 of I 1
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 CANTERBERRY CIRCLE HYANNI 02601
Owner: ANN ECENZALLI
Date of Inspection: 1/3/03
BUILDING SEWER(locate on site plan)
Depth below grade: 12"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.):
TOWN
SEPTIC TANK: X(locate on site plan)
Depth below grade: 6"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age confirmed by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000 GALLONS"
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle:33"
Scum thickness: 1"
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: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert, evidence of leakage, etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert, evidence of leakage,etc.):
n/a
Page 8 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 CANTERBERRY CIRCLE HYANNI 02601
Owner: ANN ECENZALLI
Date of Inspection: 1/3/03
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a.gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: X(if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into
or out of box,etc.):
D-BOX WAS VIDEO INSPECTED AND APPEARS TO BE STRUCTURALLY SOUND.
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no):NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a
R
Page 9 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 CANTERBERRY CIRCLE HYANNI 02601
Owner: ANN ECENZALLI
Date of Inspection: 1/3/03
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a
Type
n/a leaching pits, number: n/a
INFILTRATORS leaching chambers, number: 4
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a leaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.):
THE LEACH FIELD APPEARS TO BE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY. SYSTEM
SHOWS NO SIGNS OF FAILURE.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a.
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation,etc.):
n/a
a
Page 10 of 1 I
OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 17 CANTERBERRY CIRCLE HYANNI 02601
Owner: ANN ECENZALLI
Date of Inspection: 1/3/03
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.
Ic i
1*,-,
N
�r
Pagt 1 1 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 17 CANTERBERRY CIRCLE HYANNI 02601
Owner: ANN ECENZALLI
Date of Inspection: 113103
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 10+ feet
Please indicate(check)all methods used to determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation)
NO Accessed USGS database-explain: n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 10+FT.
TOWN OF BARNSTABLE
LQ,CATION / 7 SEWAGE
VII,LP;GE �/ y n N>y/S ASSESSOR'S MAP & LOT . I.
INSTAL UER'S NAME&PHONE NO.
SEPTV, TANK CAPACITY /O O a 94
i
CHING FACILITY: (type) 1i-2 A v 2.S- (size)
OFBEDROOMS
DER OR OWNER /4)A C vs e., j
PERMITDATE: 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 of leaching facility) Feet
f Furnished by
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TOWN OF BARNST/ABLE . . Ca
LOCATION Z 7 Ca19)?I4ul v Gis/'GG�. SEWAGE # 2--AW-M6
VILLAGE ASSESSOR'S MAP & LOT Z
'INSTALLER'S NAME&PHONE NO. 6g®rf"e- f®019.51% -7 71
L' SEPTIC TANK CAPACITY°.~ I O<o (,�l¢G
w�'L tin/a�� �l� 4636'4'
LEACHING FACILITY: (type) �' � (size)
NO._OF BEDROOMS 3
2UILDER OR OWNER
PERMTTDATE'- 3�-��-� COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility S'� Feet
Private Water Supply Well and Leaching Facility (If any wells exist /
on site or within 200 feet of leaching facility) a Feet
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by �Gt
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i
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w
t
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ti� � J
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�� -
No. ODO [ Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pphration for Mi.5pogaf *pgtem Congtruction Permit
Application for a Permit to Construct( )Repair(y)Upgrade( )Abandon( ) ❑Complete System I individual Components
Location Address or Lot No. u Owner's Name, ddress an Tel.No.
l7 G2'�y` /' �y //��/w S�eff
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No.`7 Designer's Name,Address and Tel.No.
CIO e61171_1
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder
Other Type of Building No.of Persons Showers( ) Cafeteria(' )
Other Fixtures
Design Flow /la gallons per day. Calculated daily flow 'av 3el.) gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank "I-51-s19 /!0®d Type of S.A.S. —111 45eZ
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued th's Board f Health.
Signed Date or
Application Approved by Date ?Izi,=,
Application Disapproved for a following reasons
Permit No. Date Issued
No. Ong— Q/� Fee G
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
_ -5 PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS Yes
ZIpplication for Miquar *pztem Construction Permit
Application for a Permit to Construct( )Repair(✓)Upgrade( )Abandon( ) ❑Complete System 196ividual Components
Location Address or Lot No./7 Ga'rI tel J U��/f ei1/�, Owner's Name,Address an Tel.No.
Map/Parcel Assessor's Ma G� tr/+�AGI
., P
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq. ft. Garbage Grinder(AV
Other Type of Building Aiyeeer No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow 3 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank ,�X%57`�A9 �Ot?D' Type of S.A.S. �'l!/y/ C4 Z_W -i/.//o/br,5
Description of Soil:
Nature of Repairs or Alterations(Answer when applicable) _ - )x//e
Date last inspected:
Agreement:
' The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b th's Board f Health. r
Signed Date 3/✓���®
Application Approved by Date -10. �
Application Disapproved for the following reasons
s
Permit No. Date Issued
-- — ——————————
—————————————
\
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
A+'
(Certificate of (Compliance
THIS IS TO CERTJFY,that the On-site Sewage Disposal System Constructed( )Repaired(&--)Upgraded( )
Abandoned( )by eeD/
at 5 Cz �lV G' 61 C%r has been constructed in accordance
with the provisions of Title 5 and the for`Disposal System Construction Permit No. dated
Installer Designer
The issuance of this permit shal'note construed as a guarantee that the syst! will`E ctionJ as des tg ed. .1t , r
Date � Inspector
I
No. o l x� Q Z`7 l —��1 Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Misposal 6potem on5truction Permit
Permission is hereby granted to Construct( Repair(✓)Upgrade( )Abandon( )
System located at / 7 �l?f'! ��/ C ✓G��' / �/Q�y//_j
i
4"
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit. .
Date: —�_ D� Approved by ;�
1/6/99
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I, A9_9)er1_J hereby certify that the application for disposal works
construction permit signed by me dated �J���� , concerning the
property located at / 7 4!�a`*1'44WY G�,^c� meets all of the
following criteria:
VThe failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
W The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 feet of the proposed septic system
l/There are no private wells within 150 feet of theproposed septic system
Ther
e is no increase to flaw and/or change in use proposed
There are no variances requested or needed.
�' The bottom'of the proposed leaching facility will not be located less than five feet above the
ma..dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
ethod when applicable]
If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) 5 t 7
B) G.W. Elevation Z 1+the MAX High G.W. Adjustment.31 C/ _ Z-T- 6
DIFFERENCE BETWEEN A and B '
SIGNED : DATE: '3/mlay
[Sketch proposed plan of system on back].
q:health folder:cert
tt �
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- � TOWN OF BARNSTABLE
1 LOCATION V Cil'G/
SEWAGE # 2,4BG'-706
VILLAGE ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. AOerrf'd Le,�� �i��s�; 7 71 7�!3yq
SEPTIC TANK,CAPACITY
I i
LEACHING FACILITY: wee to/0rJ 4/ (siz
e)) /Dr
a
,
NO.OF BEDROOMS 3
BUILDER OR OWNER nrG
PERMITDATE: 3-3,7 COMPLIANCE DATE: r-
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility. S 4 Feet
Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) 10 Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by �Gz
1
I .
0
I.
f
I -
.. Fs No...... - �......r ".. .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
........ _......................
Appliration for 15ispo. al Work, ( oustrurtt.un Vatnit
Application is hereby made fora Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
... ...........
Loca' Iddres No.or Lot
...�.� . :.. . . : .. ,...... - .. _.. ... ---•-----------------
Owner Address
a ...... .. ........L -A-11 .:...... (...................... ............. 2.a� .. ...............................
....... ... .. ...
In r Address �
Type of Building e''' Size Lot... ��L C�. .Sq. feet
Dwelling—No. of Bedrooms.............3..........................Expansion Attic ( ) Garbage Grinder ( )
a Other—Type of Building No. of persons............................ Showers — Cafeteria
a Other fixtures. ............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.._ f�.. Diameter.................... Depth below inlet------............. Total leaching area 1. ft.
z Other Distribution box (- Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................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.-_.•._-__-_._-.._-_---.
O Description of Soil ;; •• •- of .. . ......--•---•---•.--•••••-•••••-----•-•-••-•-•••................
1L.
W
-----------------------------------------------------------------------------------------•----------- _----- -----------•-••----••-•---------------•----••••-•-•••--•-•-------------•-••.........---
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 NI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has be issued by the board of th.
a ,
Signed... y - & ? L�< �
Date
ApplicationApproved By............................... •-• ......................................................... .
TV
Application Disapproved for the following reasons-----------------------------------------------------------------------------------••-••••...........••-••......
--------------•-------...----------------------------------•-•---------------•-------------....------•--•-••••-•--••••-•••••------•------•-•0/ate
•••--•••-••••••-......---•--............•-
Date
PermitNo......................................................... Issued-•-- .... - -3...............
No..- ............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............... __...................OF......................................................................................
Appliratiou for Binposal Worko Toustrurtiou Vvermit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
Sy
at.. ......................................... . ........ ...... ... .................................................................... ........................
..........
Locapph-'Address .7 or Lot No.
s.
....................... ..................... . ...............................
Oyner Address
................ ... ........... ...............................
................................................ .......
PAddress
U
Type of Building V Size Lot.... Sq. feet
Dwelling—No. of Bedrooms..............3..........................Expansion Attic Garbage Grinder
04 Other—Type of Building ............................ No. of persons........_................... Showers Cafeteria
PL4Other fixturp-,................................................................................................... ..........................
Design Flow......................J.... ......... .gallons per person per day. Total daily flow....... .................................gallons.
P4 Septic Tank—Liquid capacitylls�".'!.gallons Length................ Width_...__...___..__ Diameter................ Depth._....._........
Disposal Trench—No..................... Width.................... Total Length......__._._....._..Total leaching area.......�-)...........sq. ft.
Seepage Pit No_ Diameter.................... Depth below inlet.................... Total leaching area..' 1.Vv_'.sq. ft.
Z Other Distributioi Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit...._..__......_.... Depth to ground water........._...........__.
(14 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P4 ................ ................ -------------*............... ...................................................................
T 0 Description of Soil............... 'c
.............. ....... ......................................................................................................
U ....................................................................................................................................................... .............................................
W
........................................................................................................................................................................................................
:3�
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 be issued by the boardA
K"Signed. ................. ......................................... ...............................
Date
Application Approved By............................... .......................................................... ....
----------
Application Disapproved for the following reasons:................................................................................................................
......................................................................................................................................................L.................................................
Date
PermitNo......................................................... Issued.........................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF........ .... ...................................................................
Tatifirate of 'W"Umplinurt
THIS I T0,1 C RTIR�;N • constructed (V) or Repaired the Individual Sewage Disposal System That
b -----------------
----------------------------------------------- --
---------------- ------
y_
Installer
at.. 04. . ........... & ....................................................................
has been installed in accordance with the provisionsof Article XI of The State Sanitary Cole as described in the
application for Disposal Works Construction Permit No.................. ... dated..-.41--- .
THE ISSUANCE OF 3P'UARA,XH)S CERTIFICATE SHALL NOT BE CONSTRUED AS 14TEE THAT THE
SYSTEM WILL FU T SAMFAe3ORY.
................... . ..................... .......i( ..
DATE.................... Inspector.......... ......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............OF.......... .
.......... ... ..... .... ............. .....................—
..............................
......... ... FEE.......................
Permission is hereby granted................1)_Zt 7 7.............o.61747.................................................................................
.. .... ........ ... . ... ..........
to Construct(X ) or Repair ),..an.-Individual Sewage Disp9sal 5ystem
atNo........................... ./Z ..... .............................................................. .... ............. .............. .......... .. .. ....
Street
I'D�/ 7
fw
as shown on the application for Disposal Works Construction Ppimit No..-.:........E...... Dated____-':. ...........
......................--------------------- ---------------------------/.............................
e jp Board of Health
DATE. . �............................ .... ....
FORM 1255 HOBBS & WARREN. INS' PV13LISHERS