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HomeMy WebLinkAbout0077 CANTERBURY CIRCLE - Health 77 Canterbury Circle 9 ,. Hyannis -- -- � . A= 249 - 1.23 - 018 P a A Q y TOWN OF BARNSTABLE LOCATION 17/7 NA/'�Yir 6%`e-l'o SEWAGE # VILLAGE h ( ki`S, ASSESSO, -S MAP & LOT S INSTALLER'S NAME & PHONE NO. 0hp ap/ax-/"� SEPTIC TANK CAPACITY 1600 LEACHING FACILITY:(type) /60 b (size) /'C NO. OF BEDROOMS PRIVATE WELL OR�PUBLIC WATER �24 , BUILDER OR OWNER / /? �.. DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 06 or- TOWN OF BARNSTABLE !;;?CATION &r, VILLAGE 14,1c-AT1 S ASSESSOR'S MAP&-PARCEL 'S NAME&PHONE NO... � SEPTIC TANK CAPACITY-- %UrU�O LEACHING FACILITY:(type) 1"�``� (size) /©0 NO.OF BEDROOMS OWNER 'W P-'o1-r. PERMIT DATE: ATE: it 14 1 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 - / ♦ \ \ t 4 \ h ♦ h 4 \ t t t t \ t t t t t 4 \ \ 4 ♦ ♦ \ \ \ \ t t \ 4 • \ t t t t \ t • 4 4 4 t ♦ 4 \ \ \ t • 4 4 \ t \ t t t \ \ \ 4 ♦ 4 4 ♦ ♦ 4 4 ♦ \ \ \ \ 4 \ 4 h ♦ 4 \ 8 \ 4 • \ 4 ♦ t \ t 4 h ♦ 4 12 0 G Back of House 46 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 77 Canterbury Circle _ Property Address Chris Twyffort Owner Owners Name information is required for Hyannis MA 02601 November 14, 2011 every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the �� n computer,use 1., Inspector: U only the tab key to move your Patrick M. O'Connell cursor-do not Name of Inspector use the return p key. Septic Inspection Services Co. Company Name 189 Cammett Road IL 0 Company Address Marstons Mills MA 02648 Citylrown State Zip Code 508-428-1779 SI 12855 Telephone Number License Number it3.,9 `0 Li 3 B. Certification z 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 CMS 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,x(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority \t M November 14, 2011 Job# 11-210 Inspector's SignEture 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•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 1 of 17 [ z)[11112) Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 77 Canterbury Circle Property Address Chris Twyffort Owner Owners Name information is required for Hyannis _MA 02601 November 14, 2011 every page. CltylTown 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: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Tank was not in need of pumping at time of inspection. Leachiing pit was empty with a high stain line two feet from bottom of pit. 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): l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 • Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 77 Canterbury Circle Property Address Chris Twyffort Owner Owners Name information is required for Hyannis _ MA 02601 November 14, 2011 every page. Cltyfrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 15ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 77 Canterbury Circle Property Address Chris Twyffort Owner Owner's Name information is required for Hyannis MA 02601 November 14, 2011 every page. Cltyrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if an stem is functioning pp y) determines that the system g in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow t5ins•11/10 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 77 Canterbury Circle Property Address Chris Twyffort Owner Owners Name information is required for Hyannis MA 02601 every page. cltyfrown State Zip Code Date of Inspection' ton er 2011 B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. (Sins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 77 Canterbury Circle Property Address Chris Twyffort Owner Owners Name information is required for Hyannis MA 02601 November 14, 2011 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ❑ ® Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ❑ ® Was the 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 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 77 Canterbury Circle Property Address Chris Twyffort Owner Owners Name information is required for Hyannis MA 02601 November 14, 2011 every page. Cltylrown _ 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? [if yes separate inspection required] ❑ Yes ® No 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: Unknown Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts T Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 77 Canterbury Circle _ Property Address Chris Twyffort Owner Owners Name information is required for Hyannis MA 02601 November 14, 2011 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: None 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•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 77 Canterbury Circle Property Address Chris Twyffort Owner Owner's Name information is required for Hyannis MA 02601 November 14, 2011 every page. Cltylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Overflow pit installed in 1986 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 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: 8.5' long x 5.2'wide- 1000 gal. Sludge depth: 3" t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 77 Canterbury Circle Property Address Chris Twyffort Owner Owners Name information is required for Hyannis _ MA 02601 November 14, 2011 every page. Cltyrrown 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 27" Scum thickness 3" 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? 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.): Liquid level was found at bottom of outlet invert, baffles were intact. 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 77 Canterbury Circle Property Address Chris Twyffort Owner Owner's Name information is required for Hyannis MA 02601 November 14, 2011 every page. Cltyrrown 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 77 Canterbury Circle Property Address Chris Twyffort Owner Owners Name information is required for Hyannis MA 02601 November 14, 2011 every page. Cltyrrown 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 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.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: l5ins•11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 77 Canterbury Circle Property Address Chris Twyffort Owner Owners Name information is required for Hyannis MA 02601 November 14, 2011 every page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: Two 6x6 pits in series. ❑ 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.): Original pit had previously failed and was not opened. Overflow pit was empty at time of inspection, observed a high stain line at 2'. - -- ....------- - 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-11/10 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 77 Canterbury Circle Property Address Chris Twyffort Owner Owner's Name information is required for Hyannis __ MA 02601 November 14, 2011 every page. Citylfown 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.): 15ins•11/10 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 77 Canterbury Circle Property Address Chris Twyffort Owner Owner's Name information is Hyannis MA 02601 November 14, 2011 required for y --____ _._._.___.._....._......._.__.. . ----._... every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawino attached cPngrataINt \ , ♦ „ 12 p Back of House 46 \ t .:.. ud Commonwealth of Massachusetts Title 5 Official Inspection Form co Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 77 Canterbury Circle _ Property Address Chris Twyffort Owner Owner's Name information is required for Hyannis _ MA 02601 November 14, 2011 every page. Cltylfown 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: 20 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: USGS topo map and town GIS. You must describe how you established the high ground water elevation: Town groundwater contour map shows water at el. 30 and topo map shows property at el. 50. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 77 Canterbury Circle Property Address Chris Twyffort Owner Owners Name information is H annis required for Y MA 02601 November 14, 2011 every 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 i t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 T • p- z�3 TROY WILLIAMS SEPTIC INSPECTIONS Certified by MA Department of Environmental Protection (508) 585-1500 19 Hummel Drive ,South Dennis, MA 02660 COMMONWEALTH OF MASSACHUSE` YS EXECUTIVE. OFFICE OF ENVIRONMENTAL A.FFAIItS DEPART'MI,N'I' OF ENVIRONMENTAL PROTECTION Y ` TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Properly Address: 77 Canterbury Circle Hyannis,MA Owner's Name: Estate of John C. Larson Owner's Address: c/o Thomas C.Paquin P.O.Box 1145,Barnstable,MA 02630 Date of Inspection: April 3,2007 Narne of Inspector: Troy M. Williams 1\ 1l Company Name: Troy Williams Septic inspections \� Mailing Addrest: 19 Hummel Drive ` South Dennis, MA 02660 ;Telephone Number. (508)385-1300 s.: 'EIZTIFICA�I:I,ON STATEMENT 1,certtfj that 1 havespersonally inspected the sewage disposal system at this address and that the information reported belowti%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 _.._ approsvc.d sN stem inspector pursuant to Section 15.340 of T ille 5(310 CMR I5.000). The syslenr "s .._. rV Passes Conditionally Passes Needs Further Evaluation b) the 1-ocal Appruving Authorir) Fails Inspector's Signature: -� Date: `//3 /0� l he system inspector shall submit a copy of this inspection report to the Approving Authority(Hoard 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 minirnum 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. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form . 6/15/2000 paee I 0f I I Page 2 of I I 011TICIA11 INSPECTION V0101 — No ff Ohl VOLUNTAIIV ASSESSMENTS SUBSIAWACE SEWAGE, WSPOSAII, SYSTEM rNSPrC`I'InN'r012M C��2`hrrrcA`I'�QN (continued) Properly Address: 77 Canterbury Circle Hyannis,MA Owner: Estate of John C.Larson Dale of luspeclion:.April 3,2007 lnspeclioll Sumruary: Check Ajj,C,D or Y?/ ALWAYS coll►plele all of Section D A. Systen►Passes. I have ant frond any infonllalion which indicales that auy of Ile failure criteria described in 310 CM12 15.303 or in 310 CM2 15.304 exist. Any tailure criteria WA evaluated are indicated below. Conu►►cuts: inf �. n✓ i. l�'s c�f Soh S f-c-i.. It. Systel►l Conditionally Passes: One or fore system components as described in the"Conditional Pass"section need to be placed or repaired.Tile sys(eill, npoll colnpletioll of lilt Ieplacenlerll Or repan', as approved by Ile Board o Ieallh, will pass. Answer yes, no or not determined(Y,N,N1)) in Ile fur the filllowing statements. I not determined"please explain. -- _—_ 'le septic lank is fetal and over 20 years old" or the septic lank(whet r metal or not) is structurally unsound, exbibtls subsiankid inflltratioll Or exhltratioll or lank failure is inu nenl. System will pass inspection if the existing lank is replaced with a complying septic tank as approved by III oard of Health. *A metal septic lank will pass inspection if it is structuially sound, no taking and if a Certificate of Compliance indicating slat tic lank is less than 20 years old is ilvailable. ND explain: Observation of sewage backup or break oul of gb static water level in the distribution box due to broken or obstructed pipe(s)or due to it broken, settled or tine en distribution box. System will pass inspection if(with approval of Board of l Ieal►ll): broken )e(s) are replaced obslr Will is removed di• ibution box is leyeled or replaced ND explain: file system rennin pltirlping more than 4 times a year fhle to broken or obstructed pipe(s).Tile system will pass inspection if(will pprnval of Ile Board of l leallil): broken pipe(s)al-c replaced obsirlleiiorl is removed N(�explain: 2 Page 3 of l 011'I+ICIA1, INSITeCTION f,ORM - NO'J' FOR VOLUNTARY ASSCSSMLNTS SIJBSUIZ ACI? SMACy 1)IS1'OSAI, S'VSTI M INSPECTION R0121VC PART A CCIZ`I'I'ICA`t'I ON (continued) Properly Address: 77 Canterbury Circle Hyannis,MA Owner: Estate of John C.Larson Date of inspectiott; April 3,2007 C. Further I valuation is 4et)uiretl by file 1141a1-41 0(f lealth: Conditions exist which require lurllieu evaluation by the 1301,rd of Ilea I Ill in order to determine if the system is failing to protect public health, safety or flit environment. 1. System will pass unless 116ard of licallll determines in accortlalice with 310 CM1t 15.3g3(1)(b) that file system is not lltncliouing in a manner which will protect public health,safely and (lie envi lament: _ Cesspool or privy is within 50 feet of it sulfate water Cesspool at-privy is wilbin 50 feet of a hurtler ing vegetated wetland or a.salt mar, 2. System will fail unless lilt lloartl tit lieallh (%hod Ptrhlic water$1 plier,if ally)tleternllncs Ihal file system is functioning it► 41 n►anner (flat protects lilt:public health, . fely and environment: `►'Ile system has it septic lank and soil absorption syslei .(SAS)and the SAS is within 100 feet of a surface water supply or h ibulary to it surface wales sup, The system has it septic leuk and SAS and Ili I AS is within it Zone I of a public water supply. _ The system has a seplic lank and SAS id the SAS is within 50 feet of a private water supply well. _ The system has a seplic tank ant AS and the SAS is less than 100 feet but 50 feet or more fiorn a private Willer supply well*". Melt t used to determine distance "'Phis systeft?passes if flue ell wafer analysis, performed al a D Ell cerlified laboratory, for coliform bacteliami4volatilcom is compounds indicates that the well is free hom pollution fiom that facility and file presence of anim is nitrogen and nitrate ni4gto is equal to or less than 5 ppm, provitled that no other lailute criltrta at riggered. A copy of the analysis nuisl be atlached to this form. 3. Olhct 3 Page el of 1 1 OFFICIAL INSPECTION FORIVI — NOT Ik)I 'VOLUN'1'AR'Y ASSESSMENTS SUBSURFACE SIB WAGE DISPOSAL� SYS1'L?lyt >INSnC+_C'T'ION FORM I'A 12'l' A Ch.12'r1rrCA�INON(enntimked) 77 Canterbmy Circle 1'roperly Address: Hyannis,MA Estate of John C.Larson Owner: April 3,2007 Dale of Inspection: 1). Syslcu► Failure Crilcri;► applicable to ;111 sysiek►ls; You nwsl indicate "yes"or"no" to each of the following for all inspections: Yes No _v**' Backup o(sewage into facility or system component clue In overloaded or clogged SAS or cesspool Discharge or pouding of el'tluenf In the surface ol'Ihe ground or surface waters clue to an overloaded or clogged SAS or cesspool V, Slalic liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool __ ✓ t_icloid depth in cesspool is less than 6"below invert or available volume is less than %day flow Required puu►piug more Ihan 11 limes ill the last year NOT due to clogged or obstructed pipe(s). Number of tinges pumped Any portion of(lie SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is witllio 100 lec, of it surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is wilhin it `Lone I of a public well Any portion of a cesspool or privy is withip 50 Icet of it private water supply well. Any porliolk of a cesspool or privy is less than 100 lcet hul greater than 50 feet from a private water supply well Willi no acceptable water quality analysis. l'1'llis sysieu► passes if file well water analysis, perforn►ed al a 11KI' eerlified laborajory,for coliform bacteria and volatile organic eon pounds indicates that the well is free(rant polluttoll iron► that facility and file presence of ammonia rrilrogcn ;k►►d nilrale nitrogen is equal it) or ICSS tl►an 5 ppm, provided Ilkat no other failure criteria are triggered. A copy of the analysis mnsl 1►e attached to (l►is foru►.l 0 (Yes/No)'I'he syslenl fails. I.have deleri►►ined that one or more of the above failure criteria exist as described in 310 CM12 15.303, Illerefore the systerik fails. The system owner should contact the Board of Ilealfh to determine what will be necessary to correct the faihire. 1i. Large Systeius: 'I'll Ile considercr a I'll-ge syslcl►► (he sysletn u►ust serve a facility tivillt it esibn flow of 10,060 bpd In 15,000 611d, You must indicate either"yes"o►"no" to eaclk tit'Ibe following: (Tile following criteria apply to large systems in addtUon u) like crll to above) Yes no _ the system is within 400 feet of a surface drjnkik water supply tie system is within 200 feel of a Iribulary a surface drinking wafer supply file system is localed in it oitrogen se hive area(Interim Wellhead Prolection Area— IWPA)or a mapped Zone 11 of a public water supply l If yolk have answerer"yes" to any que ton in Section r tlke systelrk is considered a significant Threat, Or.answered "yes" in Section Q al?ove the large stern has fajler.'File ownel-or operator of any large systelYk considered a sibniticapt lhfeat kliAer Section F r Corlett flutter SGclic tl P sllt!Il opgrade the systelp jr accordance wjll}310 ClYil2 15.304.The systen3 owi or slit d contact like appropl fate iregioiiAl office of file Qeparltnellt. Ll Page 5 of I I OFFICIA1, INSPCI CTION F()jt Y)< — NO'J'.1 011 VOLUNTARY ASSESSMENTS SUBSURFACE SEWA(.,Is I)ISPOSAJ_ SVSTV�M INSPECTION 'FORM 1['Ek><2'1' 13 Crlrcicr.lsr Property Address: 77 Canterbury Circle Hyannis,MA Owner: Estate of John C.Larson Dale of Inspection: April 3,2007 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No Puinping information was provided by the owner,occopanl, or Board of health Welt any of the systenl coillpontnls plllilped bill in the previous two weeks'? I its the sysicin leceived nal- al flows in (lie previous Iwo week periott Have large volunies of water been introduced to lilt system recenlly or as part of this inspection Were as built plans of the sysiern obtained and examined'?(if they welt not available note as N/A) Was lilt facility of dwelling inspected fur signs of sewage back up '? Was the site inspected for signs of break ont Were all syslenl components, excluding the SAS, localtd oil site ? Welt;the septic lank inanlioles uncovered, opened, apd the interior of the tank inspected for the condition of lilt baffles or tees, name ial of conslniclion, dimensions, depth of liquid, depth of sludge anti depth of scum'? _ Was the facility owner(antl occupants i(diflerenl Ilon�l owner)provided Willi information on lilt propel- maintenance of subsurface sewage disposal systems '? "'Ile slcc and1t�catt n► of 11►e Sail Absor 4i.on S s1e.u. (SA )oil (lie si1e has been tetermitled based oil: Yes no 1 _ Existing information. Vol-example, a pled at the 11041-tl of•I leallll. _ 1)elermine4 in the f dtf(if any of the fuilore criteria Iela►etl to Pali C is at issue approximation of distance is unacceptable)f 310 CMIR 15.302(3)(b)] 5 Pale 6 of i l OFFICMAI., INSI'KTION WORM — NO'l POP V0jXNTA RY ASSESSME,N'I'S SUBSUR ACE SEVVACI-e 1I$V0SA>i SYS'><'L1Yt INSPIi�C't'1<ON y+ORM SYSTEM INFORMATION I'l-operty Address: 77 Canterbury Circle Hyannis,MA Owner. Estate of John C.Larson Date of Inspection: April 3,2007 lej'OW C:ONI)r'I'IONS 12L.SIDI�N`l'IAC. Number of bedrooms(►lesion): _ Number of beclroon►s(aclual): 3 DESIGN flow based on 310 CMR 15.203 (fix example: 116 gpil x it of bedrooms): 3 3 0 Number of current residents: ot 1 Does residence bave a Barba ge Brine !o b b 6 Ic.i (yes or no): `(�5 C� c-a L1.,..,.,..��� Is laundry on a separate sewage systen►(yes or no):�o (if yes separate inspection rerluiredf Laundry system inspected(yes or no): Aill Seasonal use: (yes or oo): Water n►cter readings, if available(last 2 years usage(gpd)): 0& -rJr7ef .,/ S OS ��000 Sump pump(yes or no): /,Ju Last date of occupancy COMM `Type of establishment: Design Clow(based on 310 CNllt 15.2113 Il�isis ol'desigu Iluw(seals/persons/sglt,etc.) _—_______--- ------ Grease Ilap pl'esent(yes of Ila): - -'----- Iudaslrial waste bolding tank present(yes or no): Non-sanitary waste dischargers to the"title 5 systel yes or no): _ Water meter readings, if available: _ Last date Of occupancy/use: O7'lll?12 (des�ribc): (._.L.NElIAI,11\11--'ORIV1A'1'I0N 1'uropiug llecords Source of infornlalion: Ala �,; �_�z!' Was system humped its part of the Inspection(yes or no): If yes, volume puny)ed: _gallons -- flow was quantity pumped Litt lermined? Reason for pumping: O1?SYS'p'F.1V!< Septic tank, i+ +-6tm, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, atlaclt previous inspection records, if any) _Innovative/Alternative technology. Attach a copy of lilt;current operation and maintenance contract(to be obtained from systeul owner) Tight tank _Attach a copy of the l)L.1'approval --Other(describe): --- — -- Ai, roximate age of till components, (late ins{alled(If knt,wfn)anti source of informatioun: /J �. (.L L.(-�.JL b(..[.�i� P�. rir_a.-. Qv, S �,,ti To J r`�'�._ <-G� f • �' L,--s cry -Utto� ON tz.I�.J I (p L/ GJVH Were sewage odors detectecj when arriving at llie site(Yes or no): 6 Page 7 of l 1 0FIACIAf, INS ITCTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAG 1)1$1 0SAJ., SYSf rN1 1INSI' C`I'YON'rOrZM PA J< T C S'YS`><'1<�1Vlf rN��O�tlyrA`l('rON (coutinued) Property Address: 77 Canterbury Circle: Hyannis,MA Owner: Estate of John C.Larson Date of luspectiOu. April 3,-2007 BUILDING SEWIAt (locale on site plan) nepth below grade: Materialsofconstruction: Vcastiron _J'/40PVC ✓olher(explairl): Distance fiord private wales supply well or suction line: Ai/,9 Comments(on condition(If joints, venting, evit ctice of leakage, etc.): ♦♦�t✓)��✓t cti.,.n S h..� 1 cal �!'�t_1_.w�_1L_�/.,`�h r/ c lK- c:.-�/i/a-3<' �.c/ 4r.L o)"' h f�c b.'�1.w � . /vG.}"G. S l �, / —u �I�.wl- rn:•y b� tutu.,c_c��. . /�f'.�Kt' �.ti.� o✓f � �r✓a,.i � ' f M'"iS��'l� c`bA✓< �:h-c 1 . ��-„`.+f . � SI?PTICTANK: (locate on site plan) Depth below grade: Material of construction: ,/concrete—metal_fiberglass___polyethylene other(expluin)__—_-- _ If lank.is metal list age: _ Is age c�lnfinnetl fly�t Certificate of Compliance(yes or no): (allach a copy of, certificate) Dimensions: .S Sludge&lth Dislance from loft of sludge to bottom of outlet lee or baffle: pug" SCUM thickness: _N_O.ve_ -------- Distance From lop of scout to lop of oullet tee or baffle: 6 " Distance front botlonl of scum to bollonl of oullet lee or baffle. Ilow were dirnensions delclmined: Comments(oll puloping recollinwildal1orls, mlel and outlel lee or baffle condition, slnlclural integrity, liquid levels as related to oullet invert evidence of leaka e etc.): ";!C-�__ -.lz�U U�"-�c:,_'I_�G`- _.IcJ tiY_�-_Lh,-.se�vi'�. I�.��2 v�.-c.✓. /�.) e✓. I/l t.l., c.,� o.JC Ln O (.IWASE TRAt': __(locate on site plan) Depth below grade:_ Muleriltlofconstruction: concrete metal fiberglass xy e _other (explain): Dioleosious: _ Scorn thickness: Distance from lop of scone to lop of oullet tee or baffle: — — Distance ti:om bottom of scum tobottom of outlet fee o affle:__ Dale of last humping: — — Comments(qn pumping reconlnrendalious, inlet , ld oullet fee or baffle condition, structural integrity, liquid levels as related to outlet inveit,evidence of leaka etc.): Page 8 of I I OFFICIAL INSIII�CUI'ION 1�01ZM - NO'J' Vio VAX VN'1 A)!2Y Assr$smIILN7's SUBSURFACE sc,WAcr: 1a1S1�casA1� s�rsrrM >lNsrrcTloN ro1ZMl SYSTI+Mi INCIORM(A'lJON(canli»ned) 1'roper(y Address: 77 Canterbury Circle Hyannis,MA Ulvner: Estate of John C.Larson pale of InsPection: April 3,2007 1"llGll"!'or 1101.0ING'YANK: (lank must Ise ptimpecl at time of inspec n)(locate on site plan) Depth below grade: Material of construction: concrete nietal—_Cbeil;lass polyethylene other(explain): Dimensions: Capacity:_-- — gallons Design Flow: _.gallons/day Alain►present(yes or no): _ Alarm level:— Alarin in working orde yes or no):_ Date of last pumping:_ Comments(condition of alarnI and lloa witches,etc.): DNS'1'12CIiC1'j'1ON 14M Al 9 (if present Hoist be,opened)(locale on site plan) Depth of liquid Jevel above outlet invert: Conunenls(note if box is level and distribution to oulletsc(Iual, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): �� -� oX-- ---"—`s= =-�E—`",, ✓+o� .� l'IIIbI I' CIIAIVI13L l2: _ (locale on site plan) Pnrrtps in working ol-der(yes or no): _ Alamis in working older(yes or no):_ Comments(note coalition of pump chamber, condi n of pumps and appurtenances, etc.): 8 Page 0 of I 1 OFFICIAL IINSPECtION (CORM -NO`r t OKt 'VOtAWCARY ASSESSMENTS SIJIISIJIII�ACI SEWAG(li 01$PQSAI, SYS'I'LlM INSPEcnON 1!+611M PART C SYSTI'M >INVIO MATION (continued) Property Address. 77 Canterbury Circle Hyannis,MA Owner: Estate of John C.Larson Dale of Inspection: April 3,2007 SOIL, A13SORP'PION SYSTUM (SAS): ,J' (locale op sloe elan, excayallun nol required) If SAS not located explain why: Type ✓ leaclliug piss, number: 1 leaching ch;unbers, lnllllher: _ leaching galleries, number: leaching trenches, nuruber, length: --- —_— leaching fields, number, clirnensions:_ Overflow cesspool, number:_l S.S' -- �— - — P, -— innovative/allernative system Type/nitre of technology; Communis(note enndilion of soi(signs of hydraulic fadnrC, level of pondiog, damp soil, condition of vegetation, etc.): 1 �o�lv-t'L'J�---- '� �w __L!1�.�-[=_-E_�tLc✓f . >�y�- 1 w�+-t C SS)'OOI.S: (cesspool must beZLIL spection)(locate she plan) Number and configuration: --Depth— top of liquid w inha inverDepth of solids layer: — Deplll of scum layer:Dimensions ofcesspool:Materials of consllucliop:Indieadon i)fgrolll►dwater inflow(yes oCouunenls(note coniliiion of soil, signs , level of poniling, conclilinn ol'vegelalion etc.): 11RIVY: (locale Lill site plan) Malelials of conslruction: _ Dimensions: _ Depth of solids:_ Cnllllnelll5(note conr►itiou of soil, signs of hydnu e I•ailuri;, level of ponding, condition of vegetation,etc.): - 9 Pale 10 oI'I I OFFICIAL INSITC'I'ION FORM — NOT IVOR VOT,UN`I'ARY ASSrSSMrN'rS SUBSrJR ACL; SEWAGE DISI'QSAC. SYSUM INSPECTION Ii'012M I'A IR'I' C SYSTEM INF0101ATION (coolinued) 77 Canterbmy Circle Properly Address; Hyannis,MA Estate of John C.Larson Owner. April 3,2007 Date of Inspecliuu: SIM 1 C11 OF SEWAGE DISPOSAL SYS7 I!M Provide a sketch of the sewage disposal system including lies to at least two permanent reference landmarks or benchmarks. Locate all wells wilhiu 100 feet. I_ocate where Public Willersupply enters the building. 1 I l I I � O l I l l I I 1 I � I � i p 25 '�'' _ TV 10 G Page 1 1 of' I I { OFFICIAL. INSPECTION FORM — NOT FOR VOLUNTARY ASSI?SSMhN`I'S SUIISURFACI; SEWAG'11, UISPOSAI, SYSTEM INSrrCTION FORM I'A It`I' C SYSTEM INFORMATION (continued) Properly Addt-ess: 77 Canterbury Circle Hyannis,MA Owner: Estate of John C.Larson Dale of Inspecttou; April 3,2007 SITIC EXAM Slope Surface wafer Check cellar ✓ Shallow wells Estin,aled depth to ground water {_ li el AiJjuslcd high ground w:►Icr clevalion2 6.3, feel Please indicate(clieck) all methods used to determine Ilse high ground water elevation. _ Obtained Iron,systeu,design plans on record- Il'cllecked, time of design plan reviewed: Observed site(abutling property/observation hole wilful, 1 SU feel of SAS) ------ - Checked with local Board of l lealth-explain: Cllecketl with local excavators, installers- (attach ilucuntenlatiou)-- - — Accessed IISGS database-explain: n�,J y h--t . �L p �. 1! You ,MistlI d''e((scribe how you established the high ground wale) elevation: L I.__-__V.1�--�_..S�r��.eiJ��-L—�..=�_._„Sr:�_..�1C.__L]_.�✓_-t1_5..�_4L.�----'�-5-'L"µ-!2_�i-f..h_{�___�W✓c1/t w(�%'-e� p/' �"-- -�-----..t''---�—-1�.u...�._��.�_�r�_ Wit.--�•���3 L V V t �y. v "Mrs„ 1�4✓�. This report has been prepared and the system Inspected as of the dale of Inspection. This report is not a warranty or guarantee that the system wllt function property In the future. There have been no warranties or guarantees, either expressed,wrllten or Impiled, relpting to the system,the. InsPedlon and/of this report. II i� o � ,off � � _ 1 No. -- Fs�..... .. .. ........_ THE COMMONWEALTH OF MASSACHUSETTS , BOARD OF HEALTH `7L/ .................... .... .....OF...........................-.--....... . .. .............. Appliration for Bitip fial lVarkii Tonstrurtiun Vamit. Application is hereby made for a Permit to Construct 4-)-or Repair ( ) an Individual Sewage Disposal Syst at: ' ....... ... ...................................... ... .................................................... .. .. lcations-A�ddr ss ........ .. ::d :(s.�.'�.i .... t Lot No. Owner '1 Addregs .... , �...., ........ :. .. ..................................... � nstaller �• Address 0-1 UType of-Building� ' Size Lot.... �_ ..Sq. feet .-� Dwelling—No. of Bedrooms........:.............................Expansion Attic ( ) Garbage Grinder ( ) '04 4 Other—T e of Building No. of persons C YP g •----------•................ P -�, ,- Showers-(�''---------.Cafeteria-(o---)- Other fixtures ....--•-----•-••••-•••-•-•---•-•••......--••••••...•----••••-•--•-•......... ------ -------- -- - W Design Flow................. .._..................gallons per person per day: Total daily flow....._._ ___-_______-_-_-_-_._gallons. Septic Tank—Liquid capacity�_ gallons Length................ Width................ Diameter---------------- Depth................ x Disposal Trench—No..................... Width............4.,Fotal Length._...............__. Total leaching area____._._._..._......sq. ft. _�_ Seepage Pit No.__: _ e< Diameter.._ _ tpth below inlet.................... Total leaching area..................sq. ft. z Other Distribution box ( �g tank ( ) Percolation Test Results Performed b Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ w Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ O Description of Soil • • .............• •...-- .----••-•---••-•---.---•----------------_-•---- x 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 XI of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b en issued by the board oj health. Signed_. . ._•.... rid -........ •--•-.-.•_- ._...__.. Date Application Approved By.......................... .•--...,..... / --_?....... Date Application Disapproved for the following reasons--------------------------------................. .................. ------------------------- ...... .............. ............•---•••---•-•-••••---••-•••----•-------------••-••••----------•--•••••••-••••-----•-•-•-••-•---•-----•••••••-•......--•---•--------•---- ............................................. Date Permit No....... Issued..- --- -D / 3.-----.-..- THE FOLLOWING IS/ARE THE BEST IMAGES FROM POOR QUALITY ORIGINALS) I M ^C&L DATA N4 A Fla$: `� THE COMMONWEALTH OF MASSACHUSETTS ✓✓ BOARD OR HEALTH OF.......:............................. -- ................--......---..._.--..........- Appliration for.13ioposal Works Tonstrnrtion Prrmit Application is hereby made for a Permit to Construct ,). or Repair ( ) an Individual Sewage Disposal system.at: ' Location`' 4ddresss or Lot No ..... J S s }r�fd: .. ....... a S t ................. Owner Address ................. *� ...... f f qfi .. .rr.. .............. !t�' .1. ; - .j I �._. ....................... M Installer Address "r '<'G7 Type of Building s- >d�>°d �-�x. Size Lot._..If -711 Sq. feet Dwelling No. of Bedrooms....... `G ........Expansion Attic Garbage Grinder Other—Type of Building -------•-----••..............No. of persons._._ t -.-- Showers �f r— Cafeteria Otherfixtures ---....._--•---•-------•.............•-••--•-•..._--•--•..... ... _ . .. ........... Design Flow.......... ,. vya...... gallons per person per day. Total daily flow................. .. .___.__-_gallons. Septic Tank—Liquid�capacrty, ;:gallons Length................ Width................. Diameter _.______.__ Depth................ W Disposal Trench—No.. ___.._:;.__._.. Width-:... Total Length.................... Total leaclung area.__________.__......sq. ft. xh a >v Seepage Pit No.... 3 ,._.._ Diameter: . ..__ D.ipth below inlet..................... Totai leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by._. ._......__._c_.........................___.____._.. Date.:... ........ Test Pit No. L__.__.. _____minut,es 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_. .................. R't r y ...•--..... •---•-----•--------- ................................. 0 Description of Soil.. ............................................................. V +. W --••--•................••--------•------•--..._.....-_.._...•--•-•-•••-_.•.....:..•••---------. --..._......------••..-_. --__--•.......----••--•---•-•-•-•--•-••-•----•--•--••-•--•---••-- V 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 been issued by the board of health. r Signed F 1 3 Date Application Approved,By.................. _. :�. '.:.......................................................... Application Disapproved for the. following,reasons:............... ....................................................................................................... ........................................ ...........................................................................................................................................•................... Date Permit No.............................. ........ .. . Issued.=- - - Date - THE'COMMONWEALTH OF MASSACHUSETTS BOARD OF: HEALTH �H.....OF....... i .. z Iry -' _ fMfifirate of TiamphFanre THIS IS �'O�ERTIFK.11 at the Individual Sewage Disposal System constructed ( or Repaired ( ) F b 7f fk. ` ......... y Install " q y xr �a f a S? e s�Y qtw has lieeninstalled m accordance witlihe provisions Article oThe State Sanita ?Code as described in the application for Disposal Works Construction PermitVo:_._. ________________ dated _ __. _. __ _Z__________ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT RE 'ONSTRUE® AS A GLIARAIME'HAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE....-�.--1•Y �--------------------------•------•---•---•--- Inspector............ ....................................... THE COMMONWEALTH OF MASSACHUSETTS x µ BOARD OF HEALTH .. ....,'�.........................OF........................!?....: i......................................... . elf No ....... ....... �io�o��tl or�o Cno�a�trnrrtion rr$nit Permission is hereby granted........ .:. ............................... t. to Construct ( ) qx Repair ( ) all Individual Sewage Dispos;fr System atNo................... ,,..... ,..... ..... _..... .._.. at .. ♦ F Street c as shown on the application for Disposal-Works,ConstructiouO.Pemit No......�,;.��_,. Dated...... !_ -................. ..._._ ._ __ _ t �Y � � 13'oaid�of-FIcaith t ... ........................ r e FORM 1255�HOBBS & WARREN.ZINC ,j,PUPL1-.HERS 4'I