HomeMy WebLinkAbout0075 CEDAR STREET - Health Hyannis5 Gedar Street
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TOWN OF BARNSTABLE
LOCATION �(�� �� SEWAGE#J
VILLAGE S�-1 ASSESSOR'S MAP&PARCEL ,7
INSBR'S NAME&PHONE NO.%e� cs� �
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SEPTIC TANK CAPACITY (j 0 0 Gam, \ .
LEACHING FACILITY.(type) (size) (6cxD
NO.OF BEDROOMS C44r e,
OWNER �` \�� �)�•�
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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TOWN OF BARNSTABLE
LOCATION �✓� C� �iP 5/ SEWAGE #
VILLAGE / ASSESSOR'S MAP 6z LOT
INSTALLER'S NAME 6z PHONE NO. A & B CANCO 775-6264
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER O OWNER C Of
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED:
VARIANCE GRANTED: Yes No
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TOWN OF BARNSTABLE
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I.:CC,.`:.17' N pIS �i7lQ� SEWAGE #
`t.LAGE XS ASSESSOR'S MAP & LOT 32.911 S,
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY LE ACHING FACILITY: (type) (size) �0X
NO.OF4WAW )QMS
BUILDER OR O R C fAx \L C tts�_� ��a 1 tlLJL
�rDATE: 7mi\'t COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table lity ` Feet
Private Water Supply Well and Leaching Facility (If any wells exist
or 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.20 1 3' D 6 3 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
application for -misposal 6pstem. Construrtion Permit
Application for a Permit to Construct( ) Repair(CIS Upgrade( ) Abandon( ) [:]Complete System ❑Individual Components
Location Address or Lot No Owner's Name,Address,and Tel.No.
& -7 5 C 6o S S T b n_ R t fi d W(i T-7 4r
Assessor's Map/P c�/
Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No.
R f R D i R oo7 a�� -Fwc-,
P•b . Bb ,, 2-71 S#VOAJMz p?H O)V
Type ofBuilding: Op. o f Rt 44-
Dwelling No.of Bedrooms /"jq Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow(min.required) AAA- gpd Design flow provided AM gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
-if PSTAii Wes - 13 iJ '67-N-t gy)-rarJ 6-4& 1-2 �
T, P/+rkIV f_0r
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 Certificate of
Compliance has been issued by this Board of Health.
Si ed Date a 4-13
Application Approved by Date Z126 1Z"r3
Application Disapproved Date
for the following reasons
Permit No. 2.0 i3 —0 6 3 Date Issued Z�L�/zo13
No. 01-5— 063 Fe /00�
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
"'%,,PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
. Nplication for Misposal *pstrm Construction 3pPrmit
Application for a Permit to Construct( ) Repair(t�) Upgrade( ) Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No,.*! Owner's Name,Address,and Tel.No.
�
Assessor's Map/P cel r�5 cLoAr ST
+ oj S' WA hti R �� c ili z 7 h'
Installer's Name Address and Tel.No:, Designer's Name,Address,and Tel.No. 1
} R E fl O% �owr, nic,a " 1
f.b: PIA 0 6r(_
Type of Building: 0I.. A l
Dwelling No.of Bedrooms NA " Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures n"
Design Flow(min.required) /V14 gpd Design flow provided /VA gpd
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
1-�i57,9,j 6u X 'fe Rer't(1 GG
N - �o p-rJ,3r I Pirk����
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 Certificate of
Compliance has been issued by this Board of Health.
Si ed Date a r 6 �3
i Application Approved by Date
z a6 �
3
Application Disapproved Date
for the-following reasons
Permit No. 20 i 3 —0 6 3 Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired Upgraded( )
Abandoned( )by
at C6A+2_ 5 t has been constructed in accordance
µ� 5
with the provisions of Title 5 and the for Disposal System Construction Permit Now,3-y6 3 dated 2%4 b-01-3
Installer Designer
#bedrooms NV+ Approved design flow ,U/Q gpd
The issuance of this permit sh 11 not be construed as a guarantee that the sysm will function as esigned.
Date 7 175 Inspector-�
----- --------------------------------------------------------•----------------------------------- -------- -----------------------------
No. 1. (� — ®(9 3 Fee Z)a o
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS
Misposal 6pstem Construction 3pPrmit
Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( )
System located at ,r CC DA-2 t` 6 1 fp_A)N 15 rM✓4
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:7CnstT;tion must be completed within three years of the date of this permit.
Date 2 G f� 13 Approved by
f -
e •
Commonwealth of Massachusetts CO?
999� .
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is
required for y H annis MA 02601 February27 2013
every 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: A. General Information
When filling out
forms the n p
computer,
r,use 1. Inspector:only the tab key
to move your Patrick T. Sullivan
cursor-do not Name of Inspector
use the return
key. Ready Rooter Excavating
Company Name
P.O. Box 89
Company Address
Forestdale MA 02644
City/Town State Zip Code
508-888-6055 SI 12843
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
March 5, 2013
Inspector's Signature Date ..�
The system inspector shall submit a copy of this inspection report to the Appfong Authority (Board
of Health or DEP) within 30 days of completing this inspection. If the systemdls shared system.gr
has a design flow of 10,000 gpd or greater,the inspector and the system owner hall submit ther"
report to the appropriate regional office of the DEP. The original should be s(�'o the sysllem oQu er
\\,and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under thi conditions of, se
at that time. This inspection does not address how the system will perform n the future uiii-oer
the same or different conditions of use. c o
t5ins•1 1/10 Title 5Iciald
ion Form:Subsurf ce Sewage Disposal System•Page 1 of 1
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is required for _Hyannis MA 02601 February 27, 2013
-
every page. Cityfrown 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 determine(Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 ye old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substan .al infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing t is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pas inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating tha a tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
, 75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is Hyannis MA 02601 February 27, 2013
required for y
every page. City/Town 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 repl/rreplaced
❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is level ❑ 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 Evaluatio/stem
d by the Board of Health:
❑ Conditions exist whfurther evaluation by the Board of Health in order to determine if
the system is failinpublic health, safety or the environment.
1. System will paoard of Health determines in accordance with 310 CMR
15.303(1)(b)that ts not functioning in a manner which will protect public health,
safety and the en
N
❑ 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 3
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
. ' 75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is
required for y M annis MA 02601 February27, 2013
every 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 nd the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and S S and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS a 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 nalysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent a the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided th 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 '/2 day flow
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 4
f
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
w , ' 75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is
required for y H annis MA 02601 February27, 2013
every 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 mu/en
either"yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the sit 'n 400 feet of a surface drinking water supply
❑ ❑ the sithin 200 feet of a tributary to a surface drinking water supply
❑ ❑ the scated in a nitrogen sensitive area (Interim Wellhead Protection
Arear a mapped Zone II of a public water supply well
If you have answered "yesestion in Section E the system is considered a significant threat,
or answered "yes" in Sectie the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is Hyannis MA 02601 February 27, 2013
required for y ry
every page. Cityrrown State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
Determined in the field (if any of the failure criteria related to Part C is at issue
® El Determined
of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): /xample:
mber of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203110 gpd x#of bedrooms):
t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 6
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75A Cedar Street
Property Address
Allen White
Owner Owner's Name
informationfor y is required Hyannis MA 02601 February27, 2013
every page. CityrTown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents:
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/yearse (gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: Date
Commercial/industrial Flow Conditions:
Type of Establishment: Doctors Office
Design flow(based on 310 CMR 15.203): 670Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): Sq, Ft.
Grease trap present? ❑ Yes ® No
Industrial waste holding tank present? ❑ Yes ® No
M Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No
Water meter readings, if available: 2011= 121 GPD 2012= 165 GPD
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is required for Hyannis MA 02601 February 27, 2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Current
Date
Other(describe below):
General Information
Pumping Records:
Source of information: No previous records found
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500 gallons
gallons
How was quantity pumped determined? Site tube o truck
Reason for pumping: Maintenance j
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative technology. Attach a copy of the current operation and
maintenance contract (to be obtained from system owner) 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 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is Hyannis MA 02601 February 27, 2013
required for y
State Zip Code Date of Inspection
every page. City/Town
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
Septic tank and Leach pit installed 10/3/1982. D-box replaced w/H-20 prior to inspection. Certificates
od Compliance on file at Board of Health.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
2.5
Depth below grade: feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line. N/Afeet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
1
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
10.5'X 5.5' X 5.5' 1500 gallons
Dimensions:
4"
Sludge depth:
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is Hyannis MA 02601 February 27, 2013
required for y ry
every 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
33"
Scum thickness
4"
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? Tape measure and dip tube.
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Inlet and outlet PVC tees in place. Liquid level at outlet invert. Inlet viewed with mirror. Cover is under
a paved walkway and wooded fence. Outlet access cover within 6" of grade.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal /iberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to t 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 10
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is Hyannis MA 02601 February 27 2013
required for y ry
every page. Cityrrown 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 ❑ berglass ❑ 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.):
F '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 11
Commonwealth of Massachusetts
Title 5 Official Inspection Form.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is required for Hyannis MA 02601 February 27, 2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
011
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.):
One inlet, one outlet. New D-Box is H-20 w/metal ring and cover to grade.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pum/mber, ndition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 12
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is
required for Hyannis MA 02601 February 27, 2013
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
1-6'X 6'w/3' of
® leaching pits number: stone. b
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Liquid level in leach pit 3.5' below top of pit. High water staining 3"above current liquid level. Clean
stone visible through side walls w/ mirror. Metal ring and cover to grade.
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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is required for Hyannis MA 02601 February 27, 2013
every 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.):
i�
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil,/sofraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 14
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
75A Cedar Street
Property Address
Allen White
owner Owners Name
of required
for Hyannis MA 02601 February 27, 2013
every page. City/Town state Zip Code Date of inspection
D. System Information (cunt.)
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
ate. ,,,,�"�,� a� �c.���`•
1 J
0 �2
I 3 ;
i
t5ins-1 tno Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Commonwealth of Massachusetts
Rim
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is Hyannis MA 02601 February 27, 2013
required for y
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
>5
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed. 1982
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:
ma.water.usgs.gov terraserver-usa.com
You must describe how you established the high ground water elevation:
Test hole in 1982 to 12' (elv= 85.5) found no ground water. Base of leach pit at elv= 89.42. Accessed
local ground water contours and topo mapping No high ground water in area of system.
{
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 16
N
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
75A Cedar Street
Property Address
Allen White
Owner Owner's Name
information is Hyannis MA 02601 February 27, 2013
required for y
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
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
g2/1912015 20:49 7813375346 CLEAN SURFACE PAGE 01/03
GLEAN SURFACE DELFADING, INC .
203 Essex St. Ph: (781) 340-0816
Weymouth, mA 02188 Fax: (781) 337-5346
FACSEMILE CQM SHEET
DATE: Feb. 19, 2015
TO: Director, Asbestos & Lead Program
(617)626-6965
Director, Childhood Lead Poisoning Prevention Program
(781)774-6700
Board of Health, Town of Barnstable
(508)'790-6304
FROM: Mark S. Bianco
RE: Notification of Deleading Work
75 Cedar St. , Un. A, Hyannis, MA -ems
PAGES: 3
WAIVER #14-064-NH
Please call (781) 340-0816 if any problems with transmission.
C
92/19/2015 20:49 7el3375346 CLEAN SURFACE PAGE 02/03
RTmVER#14-064-NB
COMMONWEALTH.OF MASSACHUSETTS
Department of Labor&Industries and Department of Public Health
NOTIFICATION OF DELEADINO WORK
All sections of this fonn must be completed in order to comply
with the notification requirements of M.G.L.Ch. 111, § 197,
454 CMR 22.00 and 105 CMR 460.000 as most recently amended
File Number: (AGENCY USE)
Contractor performing project Ma S.Bra co License#DC 001055
Lead Faint Inspector Stephen Cook License#I-IM
Date of Inspection„1/30/15_
If low-risk deleading work is being performed,complete the following line:
Property Owner: N/A Agent:
Address of Proiect
Building Nwne(if any) Floor 2
Street Address 75 Cedar St Apt.No. A
City jI annisn Zip 02601
Deleading Method: Wet���Dernolifion �
Feat Ar os
Liqusd Eucapsulant eplace, eat Other
If"Other" selected,please explain
Check One: Dwelling is multi-family, 7 Mixed Used Single family
Start date 2120115 Completion date 2/28/ 5
When will work be done: A.M. X P.M. Weekends X
Project Supervisor's name Mark Bianco License# DC001055
Property Owner Ric d Nard'ni
Address 10 Lib t.
City_Fmmingham. State MA Zip 01702
Telephone. f7741217-8302
In case of emergency contact Mark Bianco
Phone: clay (617)340-0816 evening 781340-0544
(over)
�92/19/2015 20:49 7813375346 CLEAN SURFACE PAGE 03/03
Page 2 of 2
9,n 197,454 CMR 27-00 and 10S CMR 460.000,notice of the date and method($)of
aecerdarsce with Massachusetts General f aros C.111
emoval or covering of paint,plaster or other accessible Materials containing dangerous levels of lead is to be provided sad[past be received
by the fol►awiog Wneles,at least=N(IQ)days prior to the.beginning Ofdeleading.
NOTINCATIONS MAY 13E FAXED.
1, Department of tabor,Lead program+Divislon of Occupational Safety
19 Staniford Street,is*Floor,Dostoo,MA 02114 FAX:617�26-6965
2. Dir*Wr,phildbood Lead poisoning Prevention Program S Ra>ldnlgh Street,Canton,MA 02021 PAX:761-774-6700
Department of public Health,Donavan Health%Wdin&
3. Oceapaot$of dwelling atilt
4. AU other occupants of the residential premises,if any
�. Local Board of NeWeXode Enthmement Agency
6, Maasaehdsetts Didericsl Cotttmission (if premim are listed on the State Register of Historic
Places,this notification must be made upon receipt of as
oe M MA C 62 Order to Correct V'mlations or at least 30 days prior to
Boston,MA(►2Z02
FAX(617)727 5129 initintidg preventive deleading)
NOTIFICATIONS:SH�ALL BF,COMPLETED 1N THE TPARTMR1�11'OF�A.ADOR&WORiCF4RGl;DEVEIAPMEiV7.D AND SIGNED_INCOMpLjM �TtONS W1LL NOT
BE ACCEPT E)a AND Nmu OE OETURNED RY
p (1f owner or unlicensed owner's agent will be performing low-risk deleaAng work,mmpletc the following)-
Property Owner Agent(B)
Address
Telephone
I eettify that i have complied with the training requirements of the Commonweelth of Mosmehusetts Lead Poisoning Prevention and Control Regulations,105
CMR 460,175,for ownetlagent€ow-risk abatement and containment, 1 further wrtify that l army agent will be performing the following law-rim actitities
(1 have dreled all that apply):
ca iq baseboards removing doors,cabinet doors,shutters
app i�id enapsulant PP g
applywi;exterior vinylsiding covering surfaces
i certify that all the inimnt Lion aontehud in this notification Is true aMd eoffta to the best of my r Imowledgc end belief,
Date44/g-
t
Signed
revised 12RA07
Commonwealth of Massachusetts
W Title 5 Official Inspection Form 6?
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
Y
;M 75 Cedar St. aa I
r�l
Property Address
Robert Franey
Owner Owner's Name,
information is required for Hyannis Ma. 02675 7/20/2007
every 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.
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC
Company Name .
r� P.O.Box 763
Company Address ,
Centerville Ma. 02632
City/Town State Zip Code
(508)428-4028 S14454
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 S tion 15340 of
Title 5 (310 CMR 15.000).The system: '
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further valuation by the Local Approving Authority
��'fjO ct lO� Ins or's na a Date
I 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.
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 75 Cedar St.
Property Address
Robert Franey
Owner Owner's Name
information is Hyannis
Ma. 02675 7/20/2007
required for y
every 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:
The septic,system is in proper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health,will pass.
Answer yes, no or not determined (Y, N, ND) in the ❑for the following statements. If"not
determined," please explain.
❑ The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent.
System will pass inspection if the existing tank is replaced with a complying septic tank as
approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and.if a Certificate
of Compliance indicating that the tank is less than 20 years old is available.
ND Explain:
❑ Observation of sewage backup or break out or high static water level in the distribution box due
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
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Cedar St.
M
Property Address
Robert Franey
Owner Owner's Name
information is required for Hyannis Ma. 02675 7/20/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced
❑ obstruction is removed
ND Explain:
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.
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 75 Cedar St.
Property Address
Robert Franey
Owner Owner's Name
information is required for H annis Ma. 02675 7/20/2007
y
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the.Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well`*.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
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
El ® Liquid depth'in cesspool is less than 6" below invert or available volume is less
than 1h day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
i
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 75 Cedar St.
Property Address
Robert Franey
Owner Owner's Name
information is required for Hyannis Ma. 02675 7/20/2007
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.):
Yes No
❑ ® 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
MIf 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.
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 75 Cedar St.
Property Address
Robert Franey
Owner Owner's Name
information is Hyannis
Ma. 02675 7/20/2007
required for y
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.
EI ® 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)]
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
u W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
75 Cedar St.
Property Address
Robert Franey
Owner Owner's Name
information is required for Hyannis Ma. 02675 7/20/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
Number of current residents:
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));
Sump pump? ❑ Yes ❑ No
.Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Medical office
Type of Establishment:
n flow'
(based based on 310 CMR 15.203
g ( ) 440 Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.): 6 persons
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:,
2005:100,500 2006:117,000
Last date of occupancy/use: 7/19/2007
Date
Other(describe):
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
I
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary.Assessments
M 75 Cedar St.
Property Address
Robert Franey r
Owner Owner's Name
information is required for Hyannis Ma. 02675 7/20/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records: -
Source of information: Capewide Enterprises,LLC
Was system pumped as part of the inspection? ® Yes ❑ No
If yes, volume pumped: 1500
gallons
How was quantity pumped determined? measured
Reason for pumping: maintenance
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
r Approximate.age of all components, date installed (if known)and source of information:
1982
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 75 Cedar St.
Property Address
Robert Franey
Owner Owner's Name
information is required for Hyannis Ma. 02675 7/20/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (coat.)
Building Sewer(locate on site plan):
Depth below grade: 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.):
Joints appear tight.No evidence of Ieakage.System vented through the building vents.
Septic Tank (locate on site plan):
1'
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑-polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
---------------------------- --------------------------------------------------------------------------------------------"
Dimensions: 1 0'6"x5'1 0"x5T'
Sludge depth: 0
Distance.from top of sludge to bottom of outlet tee or baffle na
Scum thickness
Distance from top of scum'to top of outlet tee or baffle na
Distance from bottom of scum to bottom of outlet tee or baffle na
How were dimensions determined? tank pumped
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
Commonwealth of Massachusetts
W Title 5 .Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
° 75 Cedar St.
M
Property Address
Robert Franey
Owner Owner's Name
information is y
required for Hyannis Ma. 02675 7/20/2007
every 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.):
Pump tank every 2-3 years.inlet and outlet tees are in place.No evidence of Ieakage.Tank appears
structurally sound.
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
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):
t5insp•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
1y 75 Cedar St.
Property Address
Robert Franey
Owner Owner's Name
information is required for Hyannis Ma. 02675 7/20/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Tight or Holding Tank (cont.)
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
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
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.):
Box is Ievel.Box has 1 outlet Iateral.No evidence of solids carryover.No evidence of leakage into or
out of box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
• Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 75 Cedar St.
Property Address
Robert Franey
Owner Owner's Name
information is required for Hyannis Ma. 02675 7/20/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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:
Type:
® leaching pits number: 1-1000gallon LP
❑ 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.):
Sandy dry soil.No signs of hydraulic failure.No ponding or damp soil.Leaching pit water to invert was
5' at time of inspection.Stain line was 3'6"to invert.
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 75 Cedar St.
Property Address
Robert Franey
Owner Owner's Name
information is required for Hyannis Ma. 02675 7/20/2007
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
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
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.):
f
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
' 75 Cedar St.
Property Address
Robert Franey
Owner Owner's Name
information is
required for Hyannis Ma. 02675 7/20/2007
every page. City/Town State Zip Code Date of Inspection
l �
D. System Information (cont.).
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.
J A $
O Q t goo C"sT'
® `10' goy
t
-�lc TAmIc 1�J O '
►_ T S�
o To S,VnCWIt �+
Sox Z Z ' �"a•�,8dX 25
PIT3° g 3z '
t5insp•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 75 Cedar St.
Property Address
Robert Franey
Owner Owner's Name
information is required for Hyannis Ma.. 02675 7/20/2007
every 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 ground water: fee Bottom of LP
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:
As-Built Card
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Used:Gaherty& Miller model 12/16/94 ground water elevations. Used:USGS observation data June
1992. Used:Technical bulletin 92-000-01 plate#2 annual ranges of ground water elevations.
t5insp 08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
Town of Barnstable
OF THE Tp�
Regulatory Services
snuvs-rns Thomas F. Geiler, Director
prFp16 9.�A Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
I
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report,please contact the certified Septic
System Inspector who conducted the inspection.
Z_
SIX COMMONWEALTH OF MASSACHUSETTS
EXECLrI`IVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
RECEIVED
NA
PARCEL.. . 1 b�' _.� NOV s 2004
�m TOWN OF BARNSTABLE
TITLE S HEALTH DEPT.
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 7 fee,
Owner's Name: ,. t- j ¢
r
Owner's Address: 7$
Date of Ins pertion-
601
Name of Inspectorhara.&,k
please print) i
Company Name:_ 1%NMailing Address:
E �5 o;a 6 q 1
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 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
Needs Further Evaluation by the Local Approving Authority
Fails J1
Inspector's Signature;—1���.— 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 10,00o
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
....
Tbii report only describes conditions at the time of inspection and under the conditions of use at that
time. spection does not address how the system will perform in the future under the same,or different
conditWr of use, w
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of I 1
OFFICIAL INSPECTION FORM-NOS`FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART["A
CERTIFICATION(continued)
Property Address: i�r'
Owner:_G ` em
Date of inspection: l�alxf
Inspection Summary: Check A,B,C,D or E I ALWAYS complete all of Section D
A. /System Passes:
/L 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: --
EL System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need replaced or
repaired.The system,upon completion of the replacement or repair,as approved by the B d of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following stat eats.If"not determined"please
explain.
The septic tank is metal and over 20 years old*or the septic t (whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or teak a is imminent.System will pass inspection if the
existing tankk is replaced with a complying septic tank as appr ed by the Board of Health.
*A metal septic tank will pass inspection if it is sttucturall Quad,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is avail e_
ND explain:
Observation of sewage backup or out or ingh static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,se or uneven distribution box.System will pass inspection if(with
approval of Board of Health):
Token p� (s)mzeplaced
obstruction ks removed
distribution boot is beveled or replaced
ND explain:
The syste required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will
pass mspecti f(with approval of the Board of Health):
broken pipe(s)are replaced
obstruction is removed
ND explain:
2
Page 3 of I 1
OFFICIAL INSPECTION FORM:NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORIVI
PART A
CERTIFICATION(continued)
Property Address: "C
Owner: ` e --
Date of inspection:
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of He�Lnordero determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in rdance with 310 CMR 15.303(i)(b)that the
system is not functioning in a manner which will proteac public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface titer
Cesspool or privy is within 50 feet of a bordeng vegetated wetland or a salt marsh
2. System will fail unless the Board o ealth(and Public Water Supplier,if any)determines that the
system is functioning in a manner th protects the public health,safety and environment:
The system has a septic and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tribu to a surface water supply.
— The system has a se tic tank and SAS and the SAS is within a Zone I of a public water supply.
— The system has septic tank and SAS and the SAS is within 50 feet of a private water supply well.
The system a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water s ply well**_Method used to determine distance
"This syste passes if
rg the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria an as
oanic compounds indicates that the well is free from pollution from that facility and
the prese a of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure teria are triggered.A copy of the analysis must be attached to this form.
3. /th
3
Page 4 of i 1
OFFICIAL INSPECTION FORM--NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DOPOISAL SYSTEM INSPECTION FORM
IPART'.A
CERTIFICATION{continued)
Property Address: � f
�x
Owner: t
Date of Inspection:
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for ail inspections:
Yes No
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
Liquid depth in cesspool is less than 6"below invert or available volume is less than'/z day flow
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number
of times pumped
Any portion of the SAS,cesspool or privy is below high ground water elevation.
Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
(.! Any portion of a cesspool or privy is within a Zone I of a.public well.
_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_.Or Any portion of a cesspool or privy is less than i 00 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis.Uhis system passes if the well water analysis,
performed at a DEP certified I dwratory,for cafferm bacteria and volatile organic,comp�s
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 S ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attach 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 CUR 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 n*W serve a facib th a design How of 10,000 gpd to 15,000
gpd-
You must indicate either`yes"or"no-to each of the fo a
(The following criteria apply to large systems in on to the criteria above)
yes no
_ the system is within 400 feet o surface drinking water supply
_ — the system is within 200 of a tributary to a surface drinking water supply
the system is 1 in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped
Zone 11 of a p "c water supply well
If you have answ "yes"to any question in Section E the system is considered a significant threat,or answered
"Yes"in Section above the large system has failed.The owner or operator of any large system considered a
significant thr under Section E or failed under Section D shall upgrade the system in accordance with 310 CUR
15.304.The system owner should contact the appropriate regional office of the Department
e
Page 5ofII
OFFICIAL.INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL. SYSTEM INSPECTION FORM
PARS'B
CHECKLIST
Property Address: Z 6+L-br 6-1-
Owner: Cr
Date of Inspection:
Check if the following have been done You mast 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?
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?
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
_ Existing information.For example,aplan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)]
5
Page 6 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 7 Ce r" 6*
Owner: C t
Date of inspection:
F OW CONDITIONS
RESIDENTIAL.
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 15.203(for example: I 10 gpd x#of bedrooms):
Number of current residents:
Does residence have a garbage grinder(yes or no):
Is laundry on a separate sewage system(yes or no):_ [if yes separate inspection required]
Laundry system inspected(yes or no):_
Seasonal use:(yes or no):T
Water meter readings,if available(Iast 2 years usage(gpd)):
Sump pump(yes or no):
Last date of occupancy:
COMMERCIAL dINDUSTRLAL
Type of establishment: _'PoJm" o R— -e
Design flow(based on 310 CMR 15.203): 6o O apcl r
Basis of design flow(seats/persons/sgtetc.): a o p
Grease trap present(yes or no):_g
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no): d1a
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection(yes or no):_W
If yes,volume pumped: gallons—How was quantity pumped determined?
Reason for pumping:
TYPE OF SYSTEM
Q�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):
Approximate age of all components,date installed(if known)and source of information:
al7 f lzc/s
Were sewage odors detected when arriving at the site(yes or no):
6
PtLge 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
nnSYSTEM INFORMATION(continued)
Property Address:
Owner: i t
Date of Inspection: to O9
BUILDING SEWER(locate on site plan) .
Depth below grade: /9 P
Materials of construction:ecast iron _40 PVC_other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: k (locate on site plan)
Depth below grade: l
Material of construction:_Xconcrete meta} fiberglass__polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000
Sludge depth: 02 n
Distance from top of sludge to bottom of outlet tee or baffle: 3O r�
Scum thickness: 37 S.It
Distance from top of scum to top of outlet tee or baffle: a
Distance from bottom of scum to bottom of outlet tee Dr baffle: 14
4z`How were dimensions determined: 1Vet8.t�
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid Ievels
as related tjo outlet invert,evidence of leakage etc_):
6
41
GREASE TRAP:_(locate on site plan)
Depth below grade:_
Material of construction:_concrete_metal berglass_polyethylene ._other
(explain):
Dimensions:
Scum thickness:
Distance from top of scum to top outlet tee or baffle:
Distance from bottom of scum bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping ommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet inv evidence of leakage,etc.):
7
Page 8ofli
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: �+P�•er ��
Owner:
.Plate of Inspection:
'YTGBT or BOLDING TANK: (tank must be at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete me fiberglass polyethylene other(explain):
Dimensions:
Capacity: fall s
Design Flow: ons/day
Alarm present(yes or no):
Alarm level: Al working order(yes or no):
Date of last pumping:
Comments(condition alarm and float switches,etc.):
DISTRIBUTION BOX: k (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: NVu(
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage m1p or out ofbox,.ete.):
b eA!r4 el le✓ct —rc Sa "cc kf w 4,0 is%12 Ca rw a&"
PUMP CHAMBER: (locate on site p
Pumps in working order(yes or no):.
Alarms in working order(yes or
Comments(note condition of p chamber,condition of pumps and appurtenances,etc.):
I
I
i
8
Page 9 of 1 i
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SZIBSUY&ACE SE*AGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address:_7
Owner• 61 QtK
Date of Inspection: i13
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required)
If SAS not located explain why--
Type
leaching pits,number
teaching chambers,number
leaching galleries,number:
Ieaching 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.):
S5464 4AA a XG r e u,,!;'E tV w kt C
CESSPOOLS: (cesspool must be pumped 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 constructio .
Indication of ground ater inflow(yes or no):
Comments(note c dition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIV1': (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note con ' ion of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
I
k 9
s
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 110--lo,tt <5Y
Owner. G 1`
Date of Inspection: j_a(g2p
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.
30 - -
Fage 11 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address• Cfs_r 5
1n1lU�
Owner
Date of Inspection:in ( nZLA
SITE EM
Slope
Surface water
Check cellar fja
Shallow wells No
Estimated depth to ground water a5 feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
6_Accessed USGS database-explain:
You must describe how you established the 4igh ground water elevati 1
e v aA Alm
,
11
n:
No. 79 —7-6 Fee 101
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppftcation for Migooar bpztem Conotruction Permit
Application for a Permit to Construct( )Repair(grade( )Abandon( ) O Complete System dividual Components
Location Address or Lot No. '� (� S Owner's Name,Address and Tel,No.
Assessor's Map/Parcel 3
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
,;�f6 � P,,,c.,o
I` -7 -7 S` Z
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 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) '�Zs✓' � e-'/ C<� o wR
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 issue y t of h. l(` r Z,9
Signed Date /
Application Approved by _ Date l� Z
Application Disapproved for the following reaso s
Permit No. _ -7 Date Issued
'No. / / ` /� Fee r
THE COMMONWEALTH OF MASSACHU�,ETTS Entered i n�`omputer: Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pp.Yication,for Mtoaal 6p5tem Congtruction Permit
Application for a Permit to Construct( )Repair(grade( )Abandon( ) ❑Complete System 4 dividual Components
Location Address or Lot No. S" ore-, S `Owner's
/Name,Address and Tel.No.
Assessor's Map/Parcel
3 2- 7 - /G
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
? -7S`= Z
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
a
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature Repairs or Alterations(Answer when applicable) IJ X ✓ �atiti G. C. i
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,hot to place the system in operation until a Certifi-
cate of Compliance has been,issued y th' of H -- p
j, Signed - Date l— rsl — /
Application Approved by Date 4/Application Disapproved for the following reaso `
r
Permit t-
No. _2 9— ( Date Issued
------.----------------------------- --.. .
THE COMMONWEALTH OF MASSACHUSETTS
�4�.p
BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( 140pgraded( )
Abandoned( )by
at has been constructed in accordance
with the provisions of Title 5 and the for isposal System Construction Permit No. <? — G ( dated Z n
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the syst m will funct' n desig
Date _ci!�! Inspector Q.
---------------------------------------
No. — Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
lwigpogar &P.5tem ngtruction Permit
Permission is hereby granted to Construct( )Repair( ppgrade( )Abandon( )
System located at Z ):j=1 �_F,�
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 ermit.
Date: //�/2- Approved by \
F
A T ION SEWAGE PERMIT NO.
VIL-LAGE
t
I N S T A LLER'S NAME i ADDRESS
OC14 co
d U I L D E R OR WNER
�oc.�U re- o's N-i.1504
_7.5-A C aA e. 5T.
DATE PERMIT ISSUE-D $2 Ito Z /p
t
DATE COMPLIANCE ISSUED ��
a �
X
o N �
N �
O ® p
O
� o
1 i i
x �
r
No.. .. ............. Fxs. .;.......................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
-- -------------------------------------------
Appliration for Dhipoiial Workii Tomtrurtion Vrrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at,
..... .. .. ........... . .....4
ff
L at' n ddre't
r
... ... ... . ... ... ........
A
. ..................... ...... . ?. .....r.......................................
Installer Address *..e
Type of Building Size Lot..__A�. ................Sq. feet
Dwelling—No. o
U f Bedrooms.z�)e-/51-10!- .e467—.-..Expansion Attic Garbage Grinder Other—Type of Building ............................ No. of persons-----__--___-....___________ Showers Cafeteria
Otherfixtures ---------------------------------------------------------------------------------------- -------------------------------------------------------------
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
1:4 Septic Tank—Liquid capacity------------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..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit._............_.._._ Depth to ground water-------------------_---
Test Pit No. 2................minutes per inch Depth of Test Pit______..-.______-_-- Depth to ground water____-_...............__.
.............................................................................................................................................................
Descriptionof Soil........................................................................................................................................................................
................................................................................I.......................................................................................................................
-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------..............
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 TT 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the board of health.
,
Sig
.Y.....A.................W................t............f...................................................................................................................."I.....-.-.-..-........t.-
...........................................
Application Approve0.............. Date
Application ap ve o he following reasons: .
.............................. ... ....................................................----------------------------------------------------------------------------------------------------------
---------------
Date
PermitNo......................................................... Issued.......................................................
Date
9
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Appliraation for B44pog al Work.i Tonstrur#iam Vrrutit
Application is hereby made for a Permit to Construct ( or Repair ( ) an Individual Sewage Disposal
System
.. t ....
ca' n- ddre
.. . ... a ...�.! ......... ----.........�... .H!X C r
--• .... .........................................
PQ Installer Address
V / _ ._.Type of Building Size Lot____ __.._._Sq. feet
Dwelling—No. of Bedrooms. . 1 _______Expansion Attic ( Garbage Grinder (
aOther—Type of -Building _._._._ .____ __. No. of persons____________________________ Showers ( ) — Cafeteria ( )
dOther fixtures -----------------•--•--•----._..-----•--------•----•----...-•-•------•----..__.....----.._._..--•----••----•-•-••-•••••••---••••••••-•------•---------
W Design Flow..............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............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.................sq. ft.
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........................
44 Test Pit No. 2................minutes per inch.. Depth ;of Test Pit..........._: ...... Depth to ground water........................
---------------------------:-------------------------=-----..._..--•--------.....--------------...---•--•-•---------..........-.............................
ODescription of Soil----•----•----------------------------•-------------•--=--.........:----=-----••--------------=------------------------•-..............................................
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�T T LE
p 5 of the State Sanitary Code= The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has,beeR issued by the board of 1 alth.
Signed
ate
Application Approve B ------ .- `--'" - ..........,r
' Date
Application •sap ve fo the following reasons:......................_..........................................................................................
----•-•-------•- ••---------•- .... ••--------------------------------------•---••-------••--•••--------•-•-
- ---------------------------------------------------------------
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD O T
... ........................OF :::.. :.... . ......... .:.............._................
(flrrtifiratr of amp tiro—~
T CFTIFY, That the Individual Se age Disposal System construct or .Repaired ( )
bL._...: K�, ,�` . - -------•--------------�, . ----------
-------------
--------
at at ............. •••��- •-----�-----• •�/.*. - -
has been installed in accordance with the provisions of TITLE of State Sanitary Cod as scribed in the
application for Disposal Works Construction Permit No datedl %
PP P --- •----••--
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRU,ZDAS A GUARANTEE THAT THE
SYSTEM V '` FUNCTION SATISFACTORY.
/
DATE._��----- .�—.
Inspector.... _. -THE COMMONWEALTH OF,MASSACHUSETTS
BOAR OF HE L
_
r ............... � ''
............OF...... -----.+ .................
nntrnrt#ion Vrrmft
Permission i ereb ranted--� ---- - --•- ------------•-----•--•----•-••-•--•• ........................................................
Yg
to Construc or Re air, ( r an Indiai al S �osal System
atNo.. --------- f .............................. --
Street ,/J
as shown on the application for Disposal `Forks Construction Permit No. ___ ,PDated f�_______ _________..............
-=----•-••------•-••-•-•--•-----•-------•.....................................................
Board of Health
DATE...............................................................................
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS
SHEET OF 2
` 1 ,
1�5 if..
ool
.01
00
u_
p
` K
i. ~IFz+Y a
SEWAGE DES Gl�! .4 pLd�, r * .t
�I. LOCATION y....//,�%�ff'� '•? '; $ h;
/1 Tom.• G�/�}T .�c��� T � j scab : . .4 ' oaTE
7� 7 25 C PLAN REFERENCE rf!Pl1 r.
��S�S'E I:r�'/3• :, WA& CNIL ENGINEER
PETITIONER
nio
, THOMw Ii.KELLEY CO.
4$NOINEERB-8URV$YO A
LONO.POND DRIVE �'QIQ►�iv
ZZ;oi1 W6
TOP OF FOUN ATION CONCRETE COVER
° CONCRETE COVERS
•'0 4"CAST IRON "'•�
PIPE (OR 12"MAX.
EQUIV.)— MIN. 4 ORANGEBURG(OR EQUIV.)
PIPE- MIN. LEACH
PITCH 1/4"PER.FT. PITCH 1/4"PER.FT. PI PRECAST
`—I N V ��� LEACH I N G
° g DI ST. IN
� PIT OR
D EL.. o.SCa. SEPTIC TANK EL v (o.+ BOX EL SsG. �: / >= EQUIV.
o° EL. 6 . GAL ` INV IN E tD,W W .:.. 3/4"TO 11/2"
INVERT9.. EL3, �o ...
EL� ;. WASHED
w STONE:
;..
D _
-- �--6'DIA.
DIA,
° •' PROR LE OF GROUND WATER TABLE,-r7
}�i
SEWAGE DISPOSAL SYSTEM r�Y
NO SCALE?^
SOIL LOG WITNESSED BY : f
DATED 'J/ TIME. 611'A ka� BOARD OF .HEALTH r'
TEST HOLE 2 /CsiE�=� , , 3
TEST H LE I ENGINEER
ELEV. '7/1�. . . ELEV. .. . . . . .
Lot-�N1 DESIGN DATA
TOTAL ESTIMATED FLOW GALLONS/DAY.
BOTTOM LEACHING AREA •�O SO.FT./PIT
r}�V SIDE LEACHING AREA SQ.FT./ PIT
GARBAGE DISPOSAL .
TOTAL LEACHING AREA SQ.FT
,,
PERCOLATION RATEG %cc
?� .Z.. . MIN/INCH
LEACHING AREA PER. PERCOLATION RATE67,2�Q•FT:
/.V..Q.WATER ENCOUNTERED NU BER OF LEACHING PITS' . �!Y�nil.. .71 /�5`%��.
APPROVED: . . . . . .
BOARD OF HEALTH
DATE . . .
AGENT OR INSPECTOR
DIZ
s
THOM
qo Pax y�? v� L AS
V!
���rj•�' Lsi�( ���/�' KEUL
?IiOMAS'E.KELLEY CO. �
WGINURA --STJILVBStOIt$ 6?�P
L S.xl�tl ft, -$( $46 LONG POND DRIVE ONAI.�
PETITIONER IlOulu Y'AtiMOVIA MAM