HomeMy WebLinkAbout0027 COMPASS CIRCLE - Health j 27 Compass'Circle
Hyannis . P
A = 310 445'.;%T,
� o .
o
a
0
A 0 C4,4L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Name
information is required for Hy annis MA 02601 06/18/10
every page. City/Town state Zip Code Date of Inspection
a
Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your Michael Kellett
cursor-do not Name of Inspector
use the return
key. Aardvark Environmental Inspection
Company Name
P.O. Box 896
Company Address
s*�
{ East Dennis MA 02641
Citylrown State Zip Code
508-385-7608 S13742
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. 1 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
,nIle 06/19/10
Inspector's'Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer,if applicable, and the approving authority.
•
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use. - ;' 0 '
1 I._
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Name
information is required for Hy annis MA 02601 06/18/10
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/ahways 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.
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 exfiftration 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
J
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Name
information is required for Hyannis MA 02601 06/18/10
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cost.)
B) System Conditionally Passes (cunt.):
distribution box is leveled or replaced
ND Explain:
Y
❑ 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. r ,
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
WV
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Name
information is required for Hyannis MA 02601 06/18/10
every page. Cityrrown 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 overioaded or clogged SAS or cesspool
El ® 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
El than%day flow
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Name
information is required for Hyannis MA 02601 06/18/10
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
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.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M °p 27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Name
information is required for Hyannis MA 02601 06/18/10
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?
E ❑ 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)]
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
°M 27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Name
information is Hyannis MA 02601 06/18/10
rewired for y
every page. City/Town State _Tip Code Date of Inspection
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
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)):
Sump pump? ❑ Yes ® No
04/10
Last date of occupancy: 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:
Last date of occupancy/use: Date
Other(describe):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Name
information is required for Hyannis MA 02601 06/18/10
every page. Citylrown state Zip Code Date of Inspection
D. System Information (cunt.)
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Altemative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components,date installed (f known)and source of information:
06/14/07
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Name
information is required for Hyannis MA 02601 06/18/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Building Sewer(locate on site plan):
Depth below grade: 1.6
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):
1.0
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: 1000 gal
T'
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle 28"
3" .
Scum thickness
6"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scam to bottom of outlet tee or baffle
14"
How were dimensions determined? measured
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Name
information is required for y H annis MA 02601 06/18/10
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert,evidence of leakage, etc.):
The tank was sound and tight with tees in place and liquid at outlet invert.
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):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Name
information is required for Hyannis MA 02601 06/18/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Tight or Holding Tank(coat.)
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 even
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
The box was level and tight with no sign of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Name
information is required for Hyannis MA 02601 06/18/10
every page. City/Town state Zip Code Date of Inspection
D. System Information (cunt.)
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:
® leaching chambers number: 4
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/aftemative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
This system has four flow diffussors in a10'x31'feild of stone.The diffussors were dry with no sign of
ponding or failure.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Flame
information is required for Hyannis MA 02601 06/18/10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
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.):
I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Name
information is Hyannis MA 02601 06/18/10
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System tnformati n (cont.)
Sketch Of Sewage Dispo System: Provide a sketch of the sewage disposal system including ties
to at least two permanent r Yference landmarks or benchmarks. Locate all wells within 100 feet.
Locate where public water supply enters the building.
a�
u �
�s
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 27 Compas Circle
Property Address
Maressa Freitas
Owner Owner's Name
information is Hyannis MA 02601 06/18/10
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
Estimated depth to high ground water: 20.0
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database-explain:
You must describe how you established the high ground water elevation: f
USGS maps show an elevation of over 20 feet.
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Compass Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Hyannis MA 02601 1-26-10
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.
A. General Information It
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
508-495-0905 S13971
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
1-26-10
Inspector's Signatur 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.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage isposal Sy m-Pa 1 of 15
N, Commonwealth of Massachusetts
Title 5 Official Inspection, Form
Subsurface-Sewage Disposal System Form Not for Voluntary Assessments
27 Compass Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is
required for Hyannis.- MA 02601 1-26-10
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:
® 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:
System is in good working order with no sign of failure.
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.
r
* 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 official document-03108 - - 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
�M 27 Compass Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Hyannis MA 02601 1-26-10
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
t
❑ 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:
El 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.
t5msp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Compass Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner
Owner's
Name
information is
H annis MA 0 01 - -
required for Y 26 1 26 10
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
r
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than '/2 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.
❑ ' f ® Any portion of cesspool or privy is within 100,feet of a surface water supply or
tributary to a surface water supply.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 27 Compass Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Hyannis MA 02601 1-26-10.
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 CM 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
questioris in Section D.
Yes No
❑" ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
El El 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.
Lt5in,p',fficial document•03/08 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 27 Compass Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Hyannis MA 02601 1-26-10
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?
1
® ❑ 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 CM 15.302(5)]
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,
w 27 Compass Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate .1-800-966-2448)
Owner Owner's Name
information is required for Hyannis MA 02601 1-26-10 .
every page. City/Town State Zip Code Date of Inspection
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
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate 4inspection 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 10-09
,occupancy: <,,�,�, oats
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203): Gallons per day(gpd)
Basis of design'flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use: Date
Other(describe):
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 16
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Compass Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Hyannis MA 02601 1-26-10
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records::
Source of information: N/A
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/Alternafive technology.Attachi'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):
Approximate age of all components, date installed (if known) and source of information:
2007
Were sewage odors detected when arriving ?g Ing at the site. El Yes ® No
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection. Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 27 Compass Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is H required for annis MA 02601 1-26-10
i y
every page. Cfty/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 14
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.):
Good condition.
Septic Tank(locate on site plan):
8"
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:
1000gal
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or baffle
20"
Scum thickness 1
Distance from top of scum to to.p;of outlet tee or baffle 67
Distance from bottom of scum to bottom of outlet tee or baffle -
15"
How were dimensions determined? Tape
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Compass Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Hyannis MA 02601 1-26-10
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.):
Tank is in good condition with baffles installed and no sign of leakage:
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: ;d.
, :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 official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 27 Compass Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Hyannis MA 02601 1-26-10
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 0
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.):
Good condition with water at working level.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
t5insp official document•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Compass Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Hyannis MA 02601 1-26-10
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:
® leaching chambers number:
4-3'x6'
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Leach chambers in good condition and empty at inspection with no visible stain lines.
t5insp official document-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official, Inspection: Form
l Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 27 Compass Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Hyannis MA 02601 1-26-10
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,
a etc.):
t5insp official document•03/08 e. 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
27 Compass Cir
Property Address
Bank Owned (Contact David Holt.@-Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Hyannis MA 02601 1-26-10
every page. City/Town State Zip Code Date of Inspection
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 bench marks..Locate all wells within 100 feet.
Locate where public water supply enters the building.
O:t
t5insp official document-03/08- - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
^M 27 Compass Cir
Property Address
Bank Owned (Contact David Holt @ Today Real Estate 1-800-966-2448)
Owner Owner's Name
information is required for Hyannis MA 02601 1-26-10
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 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: Date
® Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
® Checked with local excavators, installers-(attach documentation)
® Accessed USGS database - explain:
You must describe how you established the high ground water elevation:
Original design plans show no groundwater at 12'.
t5insp official document•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
eN-
COMMONWIATH C FEE
Or MASSACHUSETTS
1. 1 Board of Health, O7 /'1ZA2 r , MA.
APPLICATION FOP, DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair'K Upgrade( ) Abandon( ) - ❑Complete System`*Individual Components
Location—�9 Owner's Name Z U/0- 511-e, - '
Map/Parcel# 3/10 Address 97 A1,51,0Y"6i'/4e
Lot# !�(/S Telephone#
X Installer's Name exc Designer's Name
E
Address o a. P Address
Telephone# 508 - g j 3, &0 Telephone#
Type of Building cJ11V6'1i / /r V Lot Size /,4 A0 sq.ft.
Dwelling-No.of Bedrooms J Garbage grinder ( )
Other-Type of Building No.of persons Showers ( ),Cafeteria ( )
Other Fixtures 2
Design Flow (min.required) gpd Calculated design flow Design flow provided 3 gpd
Plan: Date 7--07 Number of sheets Revision Date S-17-07
Title l/ �t,/o� /� J P-5 Il e P/7/4- 1_71,//
Description of Soil(s) �?z I /-Z, ;0?-Ivp s�
Soil Evaluator Form No. 0,5-/?Q 7 Name of Soil Evaluator 4j- 15/ Date of Evaluation 40.516 Q
DESCRIPTION OF REPAIRS OR ALTERATIONS ��,p� fCe- ���LaP�Jf I eRCH!/)6 AII~/i'
The undersigned a es to' the above described Individual Sewage Disposal System in accordance with the provisions of T 5 and
furl r,,.agrees rm a tem m operation until a Certificate of Compliance has been issued by the Board o
Signed Date N pf Assq
Cy
ILLId1A� �Je�
W
o.3&948
�G�S7EP
---------- Ss��_. ����
.�ONo
&� . ` _ ��� r '� FEE
CO N*r. 14 OF MASSAC14US ETTS
m Board of Health, MA.
APPLICATION FOP, ➢ ISPOSAL SYSTEM- CONSTRUCTION PERMIT
Application for a Permit to Construct( Repai>) Upgrade( Abandon(\) ❑Complete System_�CIndividual Components
L -ocation t Owner's Name U/
y
Map/Par el#.` 3�0 Address +
Lot# yS Telephone#
Installer's Name T �XC Designer's Name/JAW) IR46
Address O Q re 6 OZ�(ez Address f � S ly- /� ��fi�t/y/rJ
Telephone# 508 - �g '�� ()o Telephone# IsQg VV OQ
Type of Building L. //z)6 G 2� ' /� �E5l�� � Lot Size m aya t sq.ft.
1 Dwelling-No.of Bedrooms Garbage grinder (
Other-Type of Building No.of persons k 'Showers ( ),Cafeteria ( )
Other Fixtures 2 •-p
Design Flow (min.required) 3 3� gpd Calculated design flow 730
7 0 Design flow provided 33Z" gpd
Plzjn: Date 1 1/ `0 7 Number of sheets Revision Date Ste•/ d
Title AlO 625C O S S ���/�/� p1,/9
Description"of Soil(s) �"r/*t ,#Wp
Soil Evaluator Form No. D5•�7a 7 Name of Soil Evaluator Date of Evaluation 005/6 07
i
DESCRIPTION OF REPAIRS OR ALTERATIONS /�A�L�C e- 7 ���r�(y/r(�/J t e#9C H
/vet 5�
The undersigned ees to• all the above described Individual Sewage Disposal System in accordance with the provisions of T TLE 5 and
fur1=_agreesc t �6 glac -the-system in operation until a Certificate of Compliance has been issued by the Boa
Signed Date �P��H OF SSgCyG
klmlm�e
AA Q
StONAL
G�
No. f )a? FEE wo
COMMON ,WEALTH Of MASSAC14USETIS
Board of Health, MA.
CERTIFICATE OF COMPLIANCE
Description of Work: ❑Individual Component(s) ❑Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ),Repaired l61 Upgraded ( ),Abandoned O
by: -yyn eS �, c-
at
at ( OAMp/a16 C1/[ C
has e with the provisions of 310 CMR 15.00 (Title 5) and t e a roved design plans/as-built:plans relating to
a licatlon No U dated (n '1 0 7 -A 'roved-Desi :n'Flow ✓ '~; ' d
.: .PP'been ms a e m J ti PP g (gA )
Installer CTA4 XA C n i
Designer: MA_ Inspector:9' Inspector: -� Date: �,1 �1 cQ
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. 700-7 :•. FEE
COMMONWEALTH Of MASSAC14USETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission-is hereby granted to; Construct( ) Repair( ) Upgrade( ) Abandon( ) an individual sewage disposal system
at as described in the application for
Disposal System Construction Permit No. ? dated 0
Provided: Construction shall be completed within three years of the date_of this permit. 16 alld i Is must ,e met
Form 1255 Rev.5/96 A.M.Sulkin Co.Boston,MA Date - 13-0 Board of Health t/'
Town of Barnstable
Regulatory Services
Thomas F. Geiler, Director
• BARNSTABLE,
9� MASS. g Public Health Division
163q. �0
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office:.508-862-4644 Fax: 508-790-6304
Installer & Designer Certification Form
Date: Sewage Permit# �;�490 7 •-e2 Pk Assessor's Map\Parcel
Designer: /w• N�r''J Installer: (/,O�1/es cx6lRk4k
Address: �� �ya��S �5L/Jxrr> Address: /]py p o
;w I
On (n -1 '® �/b ag �,)'CA>/�'!/0 N was issued a permit to install a
(date) (installer)
septic system at o77 64o!�p*Sa Gil ae based on a design drawn by
(address)
��/o,u/i �� dated ��'/Z'd 7
(designer)
I certify that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tank. Stripout (if required) was inspected and the soils
were found satisfactory.
I certify that the septic system referenced above was installed with major changes (i.e.
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. Plan revision or
certified as-bu' by designer to follow. Stripout (if requir inspected and the soils
w e found ti factory. ,CS,k OF icy
�® WILLIAM L./,0,f SNOW �
'(Ins. ler's-S* nature) CIVIL
¢sSEONAI
(Designer' ignature) (Affix Designer's Stamp Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION.
THANK YOU.
Q:\Septic\Designer Certification Form Rev 03-09-06.doc
r
70118.MUM G 84 70" 17.000' W
m�
x<
b� b`�'Y "Y � � � e• '1 _.. �� �'4 a�S Y�•� �'• F�eat
0
ir
UW
• '~'� 45
�r
+y & Y
4
a a ry�
� s
' •,�Scw^ rye a� �. ��. €'�"� r�`��s �� �� a ��'., f �.� � ' '�
3 4
r
'�S ���4 Te � '3 °Ktd T •vL�� "�y ` � ��� y Y
y��a3 �� �•� �� � F ', ,� faa � b�a�_����� �� S` � � �n�� 'tT���" t�� � �
-
i
¢ •a„ � �. t,,, n fig_ � ��+ E P` �•�,aS ; w �s� � R � � °� 1'�,?.
�E� � ,W xa � "F.�`i ;s �, �t � ��,` 'k s �Y�i,, ����'• � "`.r tf';r �y� � :r�vw �""� �:_
r
0
•`� ;'` � � -ems „,t ��X"��: � x � � a�� F 'fir'I'�'§��� x art'z' ` i „c`- � ¢ � � ! "
70018.000' W WG 84 7 ° " ' A
1/2
1 0 1000 FEET 0 500m 948
O /STe-ik
Map created with TOFO!@ @2003 National Geographic (www.national eograp
Nitrogen Loading F,? Page 1 5/18/2007
William Snow,PE
Sewage Disposal System Repair Plan W.L.Snow,PE
Hyannis,MA 5/18/2007 16:58
Subject: Nitrogen Loading Calculation Sheet
Project: 27 Compass Circle Hyannis, MA
Number of Bedrooms: 3.ao Input
Lot Size: r 1-01 00.00 S.F. Input
Roof Area: 13a8.00 S.F. Input
Parking Area: 37s.00 S.F. Input
Natural Area: 1 000 0-0 S.F. Input
Lawn Area: 6794.001 S.F.
Flows: Nitrogen:(Title V) F 4-371-6.0-01 mg.NO3-N/Day la
Water:(Title V) 1248.00 L H20/Day 1b
Actual Nitrogen: 18214.501 mg.NO3-N/Day 2a
Actual Water: 520.5o L H20/Day 2b
Impervious Surface Nitrogen Loading: Roofs:(Nitrogen) 2ss.2o mg.NO3-N/Day 3a
Roofs:(Water) 358.94 L H20/Day 3b
Paved Surface:(Nitrogen) 1as.ss mg/S.F. 4a
Paved Surface:(Water) 97.75 US.F. 4b
Pervious Surface Nitrogen Loading: Lawn Area: s33s.ao mg. 5
Natural Area: 217.2s L 6
Estimated Title V Loading: Nitrogen: F 50470.67 mg NO3-N 7a
Water: 1921.97 L H20/Day 7b
Estimated Title V Nitrogen: 2s.26 ppm NO3-N 7c
Actual Nitrogen&Water Loading: Nitrogen: 24969.17 mg.NO3-N 8a
Water: 1194.47 L H2O/Day 8b
20.90 ppm NO3-N 8c
Cape Cod Commission Reccommended
Maximum Loading 5.oa ppm NO3-N
Pretreatment Nitrogen Loading (standard SIDS) F 23,58 ppm OF
Enhanced System Reduction(if Applicable) (Assumed 50%) 11.79
Final Nitrogen Loading(with Enhanced System) 1 11.791 c o
N
No 3694
A 0'/ST
F AL�NG��
Town of Barnstable Pit /! Z/y
Department of Regulatory Services
BARNBTABIE,
Public Health Division Date
% 9.. �e� 200 Main Street,Hyannis MA 02601
lad
Date Scheduled �G'" Time Fee Pd.
Soil Suitability Assessment for Sewage Disposal
Performed By: Witnessed By:
LOCATION& GENERAL INFORMATION
Location Address �D� ® R/?'5 a Owner's Name 00/��Q .07
Address
Assessor's Map/Parcel: VY3 Engineer's Name�V,Z.6%vo v, 'Pe
NEW CONSTRUCTION REPAIR Telephone# �JoB ~'c�/'040
Land Use 117,0y,/ Slopes(%) Surface Stones
Distances from: Open Water Body }/6fl ft Possible Wet Area L� ft Drinking Water Well �✓� ft
i
Drainage Way ft Property Line e>`16 ft Other ft
SKETCH:(Street name,dimensions of lot,exact locations of test holes&.perc tests,locate wetlands�n proximity to holes)
/2rx;1i2IAM
o S -r
No. 948
0
lSTep'�
F IONAL
F
s
iv
cn
i
I W
Parent material(geologic) � /� Depth to Bedrock
Depth to Groundwater. Standing Water in Hole: IL)4A)6 Weeping from Pit Face
Estimated Seasonal High Groundwater3Y)
DETERMINATION FOR SEASONAL HIGH WATER TABLE
Method Used: Nd1 in,
N E.
Depth Observed standing in obs.hole: A/O/J _ in. Depth to soil mottles: ;
Depth to weeping from side of obs.hole: �/J in, Groundwater Adjustment ft. 9,
Index Well# Reading Date: Index Well level r Adj,factor Rom_ Adj.Groundwater Level
PERCOLATION TEST late 5/ D Tim
i
Observation 7/7/ ?
Time at 4"
Hole# �.
Depth of Perc yA Time at 6"
Start Pre-soak Time @
Time(9"-V) - - tttB[rrrAP a Y
End Pre-soak. �� (B//b�Ns
Cam°a>i
Rate Min./Inch
Site Suitability Assessment: Site Passed Site Failed: Additional Testing Needed(Y/N)
Original: Public Health Division
Observation Hole Data To Be Completed on Back-= -----
***If percolation test is to be conducted within 100' of wetland,you must first notify the.
Barnstable Conservation Division at least one(1)week prior to beginning.
Q:\SEPTICIPERCFORM.DOC
DEEP.OBSERVATION HOLE LOG Hole#_/
Depth from Soil Horizon Soil Texture w Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling
(Structure,Stones;Boulders.
// Con is % ravel
/vv wKW
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
Consi tenc % ravel
�7 LS �Or%L %, /VorU
N5 -414# 7j76)
Lv�r�2
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders.
-; Consi to c 3' Gravel
DEEP OBSERVATION HOLE LOG Hole#
Depth from Soil Horizon Soil Texture Soil Color Soil Other
Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones;Boulders.
Consistency,%!Qra 1
`I
Flood Insurance Rate Map:
0
Above 500 year flood boundary No_ Yes
Within 500 year Boundary No 1L Yes
t
Within 100 year flood boundary No Yes
Depth of Naturally Occurring Pervious Material
Does at least four feet of naturally occurring pervious material exist in all areas observed throughout the
+ area proposed for the soil absorption system? 6-5 -
If not,what is the depth of naturally occurring p4rvious material?
Certification 6 - J qfS
tI certify that on (date)I have passed the soil evaluator examination approved by the
Department of Envir nmental Protection and that the above analysis was performed by me consistent with .
the required training,expertise and expe 'ence escribed in 310 CMR 15.017.
Signatur Date
Q:%SEPTICVERCFORM.DOC
Town of Barnstable
�OFtHB��
yP ti� Regulatory Services
BARNSI,ABLE. # Thomas F. Geiler,Director
9wA MASS. , Public Health Division
Thomas McKean,Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
April 4, 2007
Mr John Shea Jr.
Remax Parmount Realty
40 Industrial Park #300
Plymouth, MA. 02360
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5.
The septic system owned by you located at 27 Compass Circle, Hyannis, MA was last
inspected February 28th, 2007,by William L. Snow, a certified septic inspector for.the
State of Massachusetts..
The inspection of your septic system showed that your.system"Failed"under the
guidelines of 1995 TITLE 5 (310 CMR 15.00)due to.the following:
D-box deteriorated,solids in D-box,D-box overflowed in past
You have 1 year from the date of the system failure to bring the system into.compliance.
If there are any questions about this reminder, please feel free to contact the Barnstable
Health Department.
BARNSTABLE HEALTH DEPARTMENT
Tho as A. McKean, R.S., C.H.O.
Agent of the Board of Health
S-4 a--
r _
c
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
27 Compass Circle
Property Address
Option One Mortgage Corp.
Owner Owner's Name
information is ����� MA 02/28/07
required for �e
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.
Important: A. General Information
When filling out
forms on the Q
computer,use 1. Inspector:
only the tab key
to move your William L. Snow �<
cursor-do not Name of Inspector
use the return
key.
Company Name
26 Lydia's Island Road
Company Address
Wareham MA 02571
�dP! City/Town State Zip Code
5088303700
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
v ,
r 03/01/2007
In liedo-Irs Signature \ Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
M at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
27 compass circle,barnstable,me 08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15
Commonwealth of Massachusetts
F . Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 Compass Circle
Property Address
Option One Mortgage Corp.
Owner Owner's Name
information is required for Barnstable MA 02/28/07
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
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
27 compass circle,barnstable,me-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 27 Compass Circle
Property Address
Option One Mortgage Corp.
Owner Owner's Name
information is required for Barnstable MA 02/28/07
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:
I
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or 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.
27 compass circle,barnstable,me•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 27 Compass Circle
Property Address
Option One Mortgage Corp.
Owner Owner's Name
information is required for Barnstable MA 02/28/07
every page. Cityrrown 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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than Y2 day flow
El ® 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.
27 compass circle,barnstable,me-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Compass Circle
Property Address
Option One Mortgage Corp.
Owner Owner's Name
information is required for Barnstable MA 02/28/07
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
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.
27 compass circle,barnstable,me-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Compass Circle
Property Address
Option One Mortgage Corp.
Owner Owner's Name
information is required for Barnstable MA 02/28/07
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
approximation of distance is unacceptable) [310 CMR 15.302(5)]
27 compass circle,barnstable,me-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 27 Compass Circle
Property Address
Option One Mortgage Corp.
Owner Owner's Name
information is required for Barnstable MA 02/28/07
every page. Cityrrown State Zip Code Date of Inspection
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
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 ears usage d 300
9 ( Y 9 (gP ))�
Sump pump? ❑ Yes ® No
Last date of occupancy: 12/31/2006
Approx
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:
Last date of occupancy/use: Date
Other(describe):
27 compass circle,barnstable,me-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15
r
Commonwealth of Massachusetts
s Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 Compass Circle
Property Address
Option One Mortgage Corp.
Owner Owners Name
information is required for Barnstable MA 02/28/07
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: N/A
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)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information:
7 years
Were sewage odors detected when arriving at the site? ❑ Yes ® No
27 compass circle,barnstable,me•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 Compass Circle
Property Address
Option One Mortgage Corp.
Owner Owner's Name
information is required for Barnstable MA 02/28/07
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 2
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: 2+
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500 GALLON
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------------------------------------------------------------------------------------------
Dimensions:
5x11x4
Sludge depth: 1.5'
Distance from top of sludge to bottom of outlet tee or baffle 25
1,
Scum thickness
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle 6" —
How were dimensions determined? Estimated
27 compass circle,barnstable,me-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Compass Circle
Property Address
Option One Mortgage Corp.
Owner Owner's Name
information is required for Barnstable MA 02/28/07
every page. CitylT'own 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.):
Dbox deteriorated, solids in dbox, dbox overflowed in past
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):
27 compass circle,barnstable,ma-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
27 Compass Circle
Property Address
Option One Mortgage Corp.
Owner Owner's Name
information is required for Barnstable MA 02/28/07
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 1.51'
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.):
Dbox is in poor condition. Concrete spalling, solids in dbox and evidence of overflow.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
27 compass circle,barnstable,me-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15
Commonwealth of Massachusetts
.09
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 27 Compass Circle
Property Address
Option One Mortgage Corp.
Owner Owner's Name
information is required for Barnstable MA 02/28/07
every page. Cityrrown 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:
❑ leaching chambers number:
® leaching galleries number: 4
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: 4 infiltrators with stone all around
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
infiltrators dry at time of inspection
27 compass circle,barnstable,me-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
f
Commonwealth of Massachusetts
u . Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�., 27 Compass Circle
Property Address
Option One Mortgage Corp.
Owner Owner's Name
information is required for Barnstable MA 02/28/07
every page. Cityrrown 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.):
27 compass circle,barnslable,me•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
M �( 27 Compass Circle
Property Address
Option One Mortgage Corp.
Owner Owner's Name
information is required for Barnstable MA 02/28/07
every page. Cityrrown State Zip Code Date of Inspection
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.
/G c r' f�trtJf E 1 '
O � v
z 3
h yy a/.s
2j s� z
5- v / 7 '
27 compass circle,bamstable,me-08106 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
27 Compass Circle
Property Address
Option One.Mortgage Corp.
Owner Owner's Name
information is required for Barnstable MA 02/28/07
every page. Citylrown 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: 8.5'+
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: 01/05/00
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
System approved in 2000. Adding depth to system, system eff. depth &GW SEP. = 1.5'+2'+5'=8.5'
L27ss circle,barnstable,me-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
No. 1� {i1 '��f/r Fee—�:�rD
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
s
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for Dtgpo al *potent Con!arurtion Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ,individual Components
Location Address or Lot No. �pS Cw G��, Owner's Name,Address and Tel.No.
Assessor's Map/Parcel v)_- `r r f
Installer's Name,Address,and Tel.No. J Designer's Name,Address and Tel.No.
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 !Fe-,I 5Z-v!!;j of S.A.S. r,62 4L.
Description of Soil Sin
Nature of Repairs or Alterations(Answer when applicable)VWSMA-V(
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 rov' ' of Title 5 of the ronmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by t e t
Signed Date
�7
Application Approved by _ Date
Application Disapproved for the following reasons "
�< .�
Permit No. �� Date Issued
No. Feelr�Tys
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
ZippYication for Migool *pgtem (Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System Individual Components
s
Location Address or Lot No.Zz �Cy M Q Ac,< .t Owner's Name,Address and Tel.No.
c
Assessor's Map/Parcel `"� , ----"`<<a-(-,
Installer's Name,Address,and Tel.No. `1 Designer's Name,Address and Tel.No.
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 s C7 gallons per day. Calculated daily flow , ` k ' gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank �.�:��7< VW S�J._rk k_-Na4 'ype of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)r3�ST-1t4�� �`- � ` t c Vl. C_c:,o<,,-
y r
CA , t t SjC.c,-CP [a_ S ,CZ,�'/`- l Q1` G' 6�,,
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 rovisions of Title 5 of the En. ' onmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by t a� e Ith`—��
Signed Date 's
Application Approved by Date �o' OL�
Application Disapproved for the following reasons
Permit No. "_Z Date Issued
---------------------------------------
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disp sal System Constructed( )Repaired( )Upgraded
Abandoned( )by (� CA p a S 7 p N C
l.
at G�t` (' n o,&�5 c c, r S-P ��� ,��`� S has bee constructed in accordance
10
with the provisions of Title 5 and the for Disposal System Construction Permit No. . r d '- dated >
Installer / Designer
The issuance of this permit sh 11 not b onstrued as a guarantee that the system-m will function as designed. v -
1 y
Date I '"3 � � tt.� Inspector 1
----- -
----------------------- ----------
No. 1 �®` ed FeeF.
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Mwi5poOar *p5tem Congt�tion Permit
Permission is hereby granted to Construct( )Repair( )Upgrade( )Abandon( )
System located at
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 completedwithin three years of the date of this pe it.
Date:_ �-�' L Approved by /e
11669
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
b� hereby certify that the application for disposal works
construction permit signed by me dated l — 5--6 0 concerning the
property located at meets all of the
following criteria: Ir
�• The failed system is tonne✓ed to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 feet of the proposed septic system
O/There are no private wets within 150 feet of the proposed septic system
Z- 7here is no increase in flow and/or change in use proposed
There are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the
ma..6mum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimpror
method when applicable]
the S.A.S. will be located with 2j0 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the ma::.imum adjusted
groundwater table elevation,
Please complete the following:
cl r,
A) Too of Ground Surface-Elevation(using GIS information)
B) G.W. Elevation / c�_the Nfr�-'C. Figh G.W. Adjustment . I` �7
D IT EREv CE BETWEEN A and B 40
SIGNED : DATE:
(Sketch proposed Ian of system on backj.
q:health folder.cert
r
� � r
�- 7 �_ ;� I Q�l
_ � � � ��
� I
---I
3 ...
I TOWIV40F BARNSTABLE
LOCATION Cv/►i 2,It S Cis cc� SEWAGE #
VILLAGE ?-1, ASSESSOR'S MAP &LOTf
INSTALLER'S NAME&PHONE NO. Ln
_.S� %, .
I SEPTIC TANK CAPACITY _/c e el
LEACHING FACILITY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: O I ai 7(70
Separation Distance detwee en the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet q
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
I -
r✓L?
s
TOWN OF BARNSTABLE
LOCXHON !!2-7 Gig M?A!5,S crib SEWAGE#p�a '.2. A'
VIILAGE �/L� 1 .5 ASSESSOR'S MAP&PARCEL `
INSTALLERS NAME&PHONE NO. (r eGC;
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) (size)
NO.OF BEDROOMS
OWNER
PERMIT DATE: 9/3&7 COMPLIANCE DATE: (a/N
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
;ti
CDC>
Z
P,`1
� \ I
M LA V
%3 - 231 �3
L
Y
TOWIv�;;�B,,5LP 1'?S':'A13LL.
LOCATION C. ��/eQ A „ SEWAGE It
VILLAGE '
ASSESSORS MAP & LOT
R4S. ALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY Ze e e+
LEACHING FACILITY: (type) d..,fe7,rw7-,cX C (size) // 4 i
NO.OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE: n
Separation Distance. etween the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet "?
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Fees
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by _
:,
� a � . ',.
�.
1..) F-•
�� �' � ..
hy.,_
l�
. i
Si
�/V � ,.f�
' .. a.i-" �..
� Y
1
IT
TOWN OF BARNSTABLE
Loch,—,ION 7 �� ��5 S C r SEWAGE #
YII LACE it Gv�at ; ASSESSOR'S MAP&LOT
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK-CAPACM, 1,00-® G"
LEACIIQ�IG FACILITY: ( ) lo (size)
NO.OFBEDROOMS --�
BUUELDE.,R OR OWNER
PERMITDATE: CONULMNCE 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 fee of leaching facility) 1 r Feet
Furnished by
9 91
� H z
i
t
(,s W
r
t
No. 3 ....�� Firms ..'� o:.......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
/ "6✓-..-_... OF...... ............................ ..................................
Appliration for Disposal 19orks Tonstrur#iun Prrutit
Application is hereby made for a Permit to Construct (�o or Repair ( ) an Individual Sewage Disposal
Syst.....at. .... - --••---•---.. ..._- •------R-•- --- --------•.......................•-� T = _ -
` Location: d �• or Lot No.
. .. �_. � � V .....------- ---------------- ------------------------------------
Owner - • Address
Installer Address
U Type of Building Size Lot.......���_ _Sq. feet
Dwelling—No. of Bedrooms____ ______________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type T e of Buildin --. No. of persons� yp g �d� -----•---- P �„-------•------- Showers ( ) — Cafeteria ( )
Otherfixtures ------------------------------------------------------ ---•-----------•-------••--------------•--•-----------------------------------........_------
Design
Septic Tank—Liquid� gallons per person per day. Total da �.ily flow......... ...............gallons.
04 Flow
nk—Liquid capacity:_�0_ ,-gallons Length__-.�__..__. Width l........... Diameter________________ Depth................
Disposal Trench—No_______________ g g q._.._.. Width____________________ Total Length Total leaching area ft.
Seepage Pit No----------_-------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing to ( )
Percolation Test Results Performed by-__ ____ ? ... w� a ........ Date _______
a Test Pit No. 1....._----------minutes per inch Depth of Test Pit...../A�--........ Depth to ground water........................
L? Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Description of Soil_. __ � .�..r_. ... _._._____� �� __v
x Csr�
U .................•--..-•-._...--•-------•-•-----...----•----_----
•------•------------------ ••-------•-•---___--••-----•--••--•---•----•--___-•----------••-- --•--•-••--------._._.._...-----------•---•-•-•-----•--..._._._....._...._..--------•--.._..._..._.
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 iIT .; 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance haobee ss ed bySigned �-------------------------•- --------_---•-- �!
Date
ApplicationApproved By........... -/C--------•---------------------------------------------••------•--------- ..........................--- -----
Date
Application Disapproved for the ollowing reasons-------------•-----------•---•----------------------------------------------------------------------------------
..........................................•----------•----•-................--••----•--------------------•-----•----•--......--------•••-----•-•------••-•---•---•---••-----•••--•--•------•------------
Q Date
Permit No.....................................�� �JIssued._.!.... 17_f
Date .._...---•---------------.
No......1314 .Tl ° Fss........A:S.............
THE COMMONWEALTH OF MASSACHUSETTS
BOARDA
1-I EA.
4 .................OF..... -...--4..��'....-............
&OP fira#ion for Dispas al Works Tonstratr#inn ramit
Application is hereby made fora Permit to Construct (` or Repair ( ) an Individual Sewage Disposal
Sys ;t . .: .--- ... ... ................... .............................................° .. ...
Location- � '" `�, or Lot No.
_..w...... .... •`.. ...... -�......� 2.............. ..r......... .........................----•-............_................
Owner Address
y/. ............... ........
Installer Address
Type of Building `Size Lot..........?:. .Sq. feet
Dwelling—No. of Bedrooms....__:: ""��.........................Expansion Attic ( ) Garbage Grinder ( )
a`k Other—T e of Building �r✓'� No. of persons ..
Other—Type g ---------------=--------- P......------------(-------------.Showers ( ✓)..— Cafeteria.(....>.
Other fixtures -----------•--•--•...................••----•------ • -
WDesign Flow..... ..............................gallons per person per day. Total daily flow........... .................._..........gallons.
WSeptic Tank—Liquid capacity.1fX-r.-gallons Length.....`(........ Width.1........... Diameter................ Depth................
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area......q '2....sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing to ( ) _
'-' Percolation Test Results Performed by... '�?s .......� !?:�% ...... Date ....'!--���__.
14 Test Pit No. 1................minutes per inch Depth of Test Pit-----1_2......... Depth to ground water.._tY. `.!..
----------
PC4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......_.................
P.I' .....................-......... .-•---•-•---•........._.-•-•. ................. -. .................................
O Description of Soil..`.:;, s?!r_.......r 'e�-�' '... G' ...�� •............................••...
Ux --•----------------------•-•-••----------------------•---------•-------•-----
--------•...•---•-----•'-•••--•----•---•----
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 ILTL" 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee �s ed by the board of health
Signed- --- ....�---------------•--.........-----...t::........................
Date
Application Approved By.......... .� �... �'- 1
Date
Application Disapproved for thermving reasons:-•-........--•-'--•-'-•••--••--••------••-----•-•-••-•--•••••--•-------••-----•-••--•••-•-• --•-•••.......-----
........................•'-•------•----••-•-'--•-----•---••------------•..._.........._..-------•..........•----------•-----•-----••--•-•---'••-••••----•••---•-•-•-....-••----•••-•----•----•---•-•-.---
Date
Permit No.---.. 34_.,... :.:.... Issued L Y� ,�1.. -•-------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD aOF HEALTH.,.5 r;a -
Tntifiratr of Tontpliatta
THIS I,9 TO CER �FY, That the.-Individual Sewage Disposal System constructed or Repaired ( )
by.._:,a f:.:..... L..�� " c= ....................... -----------------------'--...........--=----•-•----------......---................---------•-•'-.....
Installer
at..,-e/�. ' 11<
. ._ ..... x d- - ---------------------------•------------••------.-.------------.-..-._-----•---- •---....._
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No.._.... 316.-__21........... dated..........4x--- .._.............
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUE® AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...............& :..z .................................... Inspector....................................................................................
THE COMMONWEALTH F MASq. �CHUSETTS
$� BOARD OF r=ALT1/4
No........ FEE---o`5..: . '
...._...
Permission is hereby granted. � s"'�v
to Constru t ( or Repair ( ) gn' Individual Se �" Di" & System
atNo.. / --•---•----•-••-------•---•--------••..........................................
Street
as shown on the application for Disposal Works Construction Permit No.___..=� . Dated......... t�" :'���
?e oard of Health
DATE............ Z.......................•---.........--
FORM 1255 HOBBS & WARREN, INC.. PUBLISHERS
No...... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
0 F.... ..... ...... ....
H, 'Y Appliration for Disposal Works Tonstrurtion Prrmit
Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal
System at
..........................
Location-A ress or 15aZZ 01
dress
s A - -------- --------
.....................
...
........................ __I . .. .
....Jer -------------------7....
nstaller Address
Type of Building Size Lotl . .. ........Sq. feet
Dwelling—No. of Bedrooms.......... ExpansioIlic Garbage Grinder
3 — Cafeteria
Other—Type of Building o. of persons....__._______________ Showers
P4 A
Otherfixturw---------------------------------V...............................------------------------------------ .. .............................
Design Flow...........S-3----------------------gallons per person eir dy. Total d4ilp f1QW-------- ................gallons.
P4 Septic Tank—Liquid capacity-/,W-gallons L Width-- --- Diameter---------------- Depth......_.._......
Disposal Trench—No. .................... Width_...._.._...._...... T o t AiL_-e--n-g t h............e.. ,Total leaching area----...............sq. ft.
Seepage Pit No ea &��area. ft.
....../------ ---- Diameter------- ----------
Depth below inlet..... Total l chin
Z Other Distribution Box h Dosing tank
r Percolation Test Results Performed by .... Date=
p........
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground wao------
Test Pit No. 2................minutes per inch Depth of Test Pit...............___.. Depth to ground wate
----------------- ------- -7....................................................
470... ------------]J��---------e.................
0 Description of Soil.._....:
U .........................................................................................................................................................................................................
W
Z ...............------------- ..........................................................................................................................................................................
U Nature of Repairs or Alterations—Answer when applicable-----------------------------------------------------------------------------------------------
.......................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TLI'IlE 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been ed by the board of h
Sig d..:.
Pate
Application Approved By.......
Date
Application Disapproved for the following reasons:....................
p .......................................................................
........................................................................I...............................................................................................................................
6 Date
Permit No. Issued.. 147 14Z
------------
7M
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH t
- .......
for Dispaii al Works Touptratr#inn ramit
Application is hereby made for a Permit to Construct . or Repair ( ) an Individual Sewage Disposal
System at
a ..... ............................................................. < `a � , ........................
Location-Address 'it or Lot No. �. f°�
.........--
OOP Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms........•____________________________Expansion ttic ( ) Garbage Grinder ( )
a. Other—Type of Building ) ,yp, &. , o, of persons......... ............... Showers ( ) — Cafeteria ( )
Otherfixturps -------------------------------- ---------------------------
W Design Flow...........
gallons per person peer dky. Total d�ai�ly flaw........ .................gallons.
WSeptic Tank—Liquid capac>ty( gallons Length_ ., ..... Width..;� __Diameter ............. Depth................
x Disposal Trench—No......... Width._0................ Total Length..............F..�,,,Total leaching area....................sq. ft.
Seepage Pit No....... ........... Diameter ..... _.__..._. Depth below inlet......l r''.... Total leaching,area...,� q. ft.
Z Other Distribution box O Dosing tank ( ) "
a Percolation Test Results Performed by._,:a!wy'jx, .....>' Date__
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground wa of___• ............
44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water.A.
04 •-- ---.. ... ...........-W. . ..........................................................
ODescription of Soil...... 6 1�r- .: ......................-----------------••----
x
U .._....--
-------------------------------•----------------------
W
VNature 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 TITLE 5 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. i
SM;8!
�
f ate
Application Approved BY y ``" '"'
Date
Application Disapproved for the following reasons:.....................----------.............................................................................
_
....................•--.......--------------•---------------•------------•----........-----••----......---••-•-••-•--•-•-••......_ ---••-•••-•••--------•---•--••--•••••------------•••••-••••-••.....
Date
PermsNo.... .............................................. Issued----------•----••-------------.......................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
up rdifiratr nf -Tuntph am
THIS IS TO CERTIFY That_the Individual ewage D' osal System constructed -or Repaired ( )
by • .. . ,. 1:� "....._.. "°" �`- -: ' : f ��,' . ...----- •......... .....•--------....---....--------•--------•---
at•--••--•--•• r E �, r, ins MI
:. � -------
has been installed in accordance with the provisio s f . r of Tyh State Sanitary . ode as described in the
application for Disposal Works Construction Permit No __ 'F dated .( .�
THE ISSUANCE OF THIS CERTIFICATE,SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL UNCTIONV 4T FACTORY
DATE............. -•.--•• ••. - --------. Inspector --- --.............................................• -
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�-: f sf": .'"•!f�.?.:�'.' ,r�'".'.�P�.`/..O F...... s� .�r�-r"!^.".:� �: ...�..1L...,� n �4 .. ...
r
;,.. No......... .. ...... + � �~' R... FEE....................
Eiu1ru,11tt1 nrko Torn tratrtiun- ,r4rmi1, ,J
Permission is hereby granted........L,--_
i. to Construct Repair ( ) an Individual Sewage Dis gsal System
( ) or
at No......... .. .......... * %v' =j ^' L.......f,� S eet
as shown on the application for Disposal Works Construction P ................ Dated---- '.'. _-.. ........ -'
Boa Health
DATE.....(-:'._l— jjjjj
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS - -
G
" MM.lMwwY..Y• r+w•+-wnsw.i...i...,•.,•e�y.y. M•w u.ww.w..-,a.w.._wMYYR•Mwa++w �111�r.we=•.wM.+.w.••+wM+.•M-�+.tw.rmv wrva 4+>.r.- M,+*w•..�onw,
f'AfJL+fi�+ a ( FIIV#SH 61-VADdf!41"5 rIMSN SVAV6 )VI AWA`H 617A Z
I
DvEA Ti4IV 4 lair
Top e� F"a�►�rrs. I
4 �
(' 11P1,���rruery�y�'�v+:�`A'�•!?��Jl;Jl,�rtlj��.,�,�-�� �t � / '.
,WIA O *W4VeV
C��KflLL /
c ti - - _ �• �"_3'-p��l s rd.r E
! U ,•• I � 42. � i �uv142,Z3 ��; ': ;� _._�,..�, .__'._ -�--�R_�, � Q v• 4t, 5� � �,. --;✓
/ f
V 3g 60 /G �Fs4Z• �+-t'o.¢�•od'�
P !S T
- �� ��k'�'r nrEt� CMG• .- o � �
o
.SEF'T1 C TAw K 14
T �,lj/, JjTfA�C J 507 7b y Of prof
- GE'r9Ctr/NG= l�='/T
iYa Of- .aFn0001V.S
G,9 L- ��,e nag y : '�►'�-� -
S t0el,0,0L4- AAfA: A iG, x 2,3 r�� 4Z S 3�3 I
o,sr. ±., �' �T Z I
A
7TD�tA !lr2A c AUK I,Q _SLi _ aox
o — N r000 C>A l„
d�� ExQ�'` ✓ tv _ sE�crANK iQ SF
P rT Pr[L PUS�"D . P
� COALS€ f
P E r
9/45
4 f
-Lffijjt�- vi^r&�Ljol
reV ,may ff�Por�'oSt r� �'`L>'rvG
2(. X41gy) iC.�7A
AeAbc. .eA7;f,: t_ t�f_r/
Of
NO PJJMAA
QWWSIIItAN NOJ` /!AN 6WOW! AN R�+
Swo ,4 ,'2 .,` zz4 N444Y POI.Vr R.V.
Ott,
-... S�'���.L�1�n -...•. Yv- 'F1�: .. ....«!f4l'.. ..:A�.. a� ,.. , - - _ - � .� +�- ',,fir � K•.Wi ,L,,,k:.r. r -. ;•.:� '. � '�. - 'A„ate' o.. �`.. ... f'1-u.-.t1a w .� ; .ar +w,l" �4 ma.,.3 ..,.. . .k�.... ,.,�G.+ _ 3,.. ..
i
MASH 6;eAVAF* „ �- l�t�reS v NvE F►aet`H �rltAflE _.- ---�
—— 0%,-O)lt"rA JVK_ Z OvER FAT !
a
474 e
Ott,i W--1WIM 41IV-13 M—il/er��
y
f
..v_<:.a.Ewt�r `-----�_—:�.''. ---� .�.:,....... ice.._ .. ...•. h , ,
}�
er✓ F 13 T'- 13 G x ? s z f j ✓' c eu,�,ym►c� sue-®.vd
VA
Ira Olt
Pr
CA
,,+der✓' Td �•.'+G.� _______—_— ._—___
r x t t O AI I
F�i-'r Q� A -A .. i 10 223
LOT
�oP. Uuv ;t,c..cr. 14
46
1 coo,'012.
AV
. ,2
�.�r•�-.F : �i��/"''�g�.�?•cam` °� _ -.; • a •� •
4-2
Pow
.. • �
MT-
OwN��E' -
++` ' ,dam - • u 1p�w•, a vl 1,t Y- _ '+' , *A
y,
AN ;,h vq i "" , /� Q�? /rj1 ► • !��. ,2 r
t
I a• Y
,Y
-
. x
,
V
a