HomeMy WebLinkAbout0123 CONNEMARA CIRCLE - Health L=A
3 3CONNEMARA'CIRCLE, xYi Nzs
290-137
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
123 Connemara Circle
Property Address
Owner Owners Name
information is quired for every Hyannis MA 02601 07/03/17
i re
page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important When A
fiuing out-torms
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Mike Hudson
use the return Name of Inspector
4spN,
Septic-wiz Environmental Services
�y Company Name
44 TaII Pines Dr
Company Address
Yarmouth.Port MA, 026.75
Clfyaown _. State Zip Code
508-367-5669 DEP SI#4254
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
L_I Neecls i= ner"valuation by,the LocafApproving Authority-
07/17/17
Insp r s Signatu Date
system inspector shall submit a copy o is inspection report to the Approving Authority(Board.
f Health or DEP)within 30 days of completing this inspection. If the system is a shared system or.
`nas-a 6eslgn`'iiow of `izt�vuu-gpp.or-greater;`ine'�rnspector-andiine system owner snail stiomir'ne
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. (I
t5ins'•31113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
f
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
123 Connemara Circle
Property Address
Owner Owner's Name
information is required for every Hyannis MA 02601 07/03/17
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
® 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:
U One or more system components as aeScr'iDeo iVne`uonumonav rash'see*fir n fieeo'tro'De
replaced or repaired. The system, upon comp) I n of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determ' ed" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 ars old*or the septic tank(whether metal or not) is structurally
unsound;exhibits substantial infi►tr ion or exfiltration or tank failure is imminent. System will pass
r..;.
ii`r5�7Eciiorr ii�frre eXisli•t9'`.idfrK isr piaceu"wiCr`r ci'cvrrtpiy'ii•iy aejcic iariic as-approved uy�t`r�e ovc#rq:vr""
Health.
*A metal septic tank will p ss inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating t t the tank is less than 20 years old is available.
0 Y ❑ N ❑ ND (Explain below):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
123 Connemara Circle
Property Address
UaaiN,:
Owner Owners Name
information is required for every Hyannis MA 02601 07/03/17
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
u� :Syacelri:vvria+i'eibrieiiiy ra5asa�.vll :'f.
❑ 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 ❑ ❑ N ❑ ND (Explain below):
U...,'t' LJ j:4: 1-_I FVJlt/ uv"Iviri+�.i'-.
❑ distribution box is leveled or replac ❑ Y ❑ N ❑ ND (Explain below):
❑ The sys/okenare
ping more than 4 times a year due to broken or obstructed pipe(s). The
system insion if(with approval of the Board of Health):
❑ re replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ oved ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which /rtherther eval ation by the Board of Health in order to determine if
the system is failing to blic he h, safety or the environment. .
.. __
1. Jy.Ytki'I fl-W III �la.7.7'Wftl U' 1'fl�Qll(1 UCLCIIi IIIIC.I 111 alVV�JI Ofli:IC'C:'�VIIILf'1 J.1V'Vmft-
15.303(1)(b)that the sn functioning in a mahner which will protect public health,
safety and the enviro
i
❑ Cesspool or prin 50 feet of a surface water
❑ Cesspool or prin 50 feet of a bordering vegetated wetland or a salt marsh
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Connemara Circle
Property Address
�!larv:Elnra..��ilu1S_:
Owner Owner's-Name,^ ~
information is required for every Hyannis MA 02601 07/03/17
page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that p tects the public health,
a8wi'y-'ia i�i'i'a;oll`V rl l'i1Tt�Yra.
El
-The system has a septic tank and soil absorption syste (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surfa water supply.
❑ The system has a septic tank and SAS and the S is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and t SAS is within 50 feet of a private water
supply well.
n. The.system.has..&septic,tank and SAS:;and., SAS:is.less, feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water nalysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent a the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided th no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes" or"No"to each of the following for all inspections:
❑ ® 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
Lisagid de_ tki i ss �Ql,i 1p�than. "f love ir eA oz,ayy �c4lgrR iS less .
`-` than day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 117
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
123 Connemara Circle
Property Address
R�I�aAu��tC�i�s
Owner Owner's Name
information is required for every Hyannis MA 02601 07/03/17
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes . No
ROW i.cu o .rnor�x 4 tea as jn.,th )ast.vear NOT due tov cl�c�d,
obstructed_plpe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
E,. lG�.. �i lyM'i�1�1dii.vl+la'u S�Nvvi'w1.Nl lv'y*IS r4ii(1111 Jv iG�.vT.2i`'7f1�2a1c�'rJa�cl $iiN�"i Ji'.�r'�pl:
❑ ® 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
❑ ® 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" "no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is hin 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system i located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IW ) or a mapped Zone II of a public water supply well
If you have answered"yes"to ny question in Section E the system is considered a significant threat,
or answered"yes"in Sectio D above the large system has failed. The owner or operator of any large
" een e• <rler C+4�njf ram. ++.)" 4. r..J C �
sysfem in'accordance 310 CMR 15:304. Tf a sysfern owner should�contact the appropriate
regional office of the Department.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Connemara Circle
NOR"
Address
NOcam.NMI C+00-A
Owner Owner's Name;`?.'•.
information is required for every Hyannis MA 02601 07/03/17
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:
ca :•iYv
® ❑ 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 LaKoe.volumes of watec beep.Otcoduced.to tkte.system,recently Q,c.as.part.nf.
this inspection?
® Q 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?
.Ira f.7 :�.-_.. .n%r r ,.x.v l6 �'•X c/.y]! S"' y. n � .J v.i..7' _ ,
. i if GFI;aV 'Gh 1 arG Lti+ v4.iLL+v .lG.
® '❑ 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)]
y .tee?.!n#o"l ?a
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms (actual): 3
IDESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 GPD
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form'-Not for Voluntary Assessments
123 Connemara Circle
Property.Address
Owner Owners Name:'."',
information is Hyannis MA 02601 07/03/17
required for every
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
2 Bedroom ranch
Number of current residen/enrs
0-for sale
Does residence have a ga ❑ Yes ® No
Is laundry on a separate se laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected ❑ Yes ® No
Seasonal use? ® Yes ❑ No
Water meter readings, if aa e d 2015- 1 3 GPD
gg (gP ))� 2016 - 132 GPD-
"Detail: '
Sump pump? ❑ Yes ® No
Last date of occupancy: unK.nown
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 1 . 03):,
Gallons per day(gpd)
Basis of design flow (seats/per ns/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holdin tank present? ❑ Yes ❑ No
Non-sanitary was discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Connemara Circle
Property Address
Owner Owners'Name
information is required for every Hyannis MA 02601 07/03/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Zic�
Pumping Records:
Source of information: N/A
Was system pumped as part of the inspection? ❑ Yes ® No
NA
✓`gallons
How was quantity pumped determined? N/A
Reason for pumping: N/A
Type of System:
.�. �-d� A 1' •'t+S.�¢. S .fir.�+�, T � '.:41�b �1�S h?a.
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
rl,
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest.
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
l5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
i
i .
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Connemara Circle
Property Address
Owner Owners`Name" .'.'
information is
required for every Hyannis MA 02601 07/03/17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
20�ears+31d,..�nst�llef�.1.99.7 Yi2.2s-boil#
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.1011
Material of construction:
0 cast iron 2[40 PVC ❑`other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
vented thru roof, no leaks
Septic Tank (locate on site plan):
101,
Depth*below grade: feet
' _•'iVld if7ti'.IGi�I�l��l�lfili.,hN:uliii�l'i
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: 1
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ® No
Dimensions: 1000 gallon tank
} Sludge depth: 48"(2 thickness)
y. y , •
t5ins•W13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Connemara Circle
Property Address
ttir
Owner Owner's Name
information is required for every Hyannis MA 02601 07/03/17
—
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
2
vi�idil�.cTIvjl i i-t,N vi aiuuyc C�►fvi6,-r, yrvuuc}
1„
Scum thickness'
8"
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
15"
sludge probe, mrrot flood haht.,.
snake.camera, measuring Stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Recommend pumping every 36 months, Inlet and outlet concrete baffle in average condition, tank
appears structurally sound, liquid level normal at outlet, no signs of leaks.
I
t ,
Grease Trap (locate on site plan):
Depth'below grade: feet
Material of construction:
❑ concrete ❑ metal ❑fiberglass El polyethylene El other(explain):
''Dimensions:
Scum thickness '
Distance from top of/scum
outlet tee or baffle
Distance from bottomtom of outlet tee or baffle
Date of fast pumping: Date
t5ins•3113 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
N Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Connemara Circle
Property Address.
f..Ares':�:�►4ir�5
Owner Owners Name ..:
information is required for every Hyannis MA 02601 07/03/17
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
i
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Material of construction:
❑ concrete ❑ metal ❑fiberglas ❑ polyethylene ❑ other(explain):
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of rm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
� 14 ra•'h;,y [`liim G-- i� ^-+�wir Ne__ £1 -.41 n.5�; ?-.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Connemara Circle
Property Address
Owner Owner's Name'-
required for every information is Hyannis MA 02601 07/03/17
require
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
ucNmi^vi iiyuiu ic4ci=a i'v''vcf"uuii `i'lI V=1 i
•Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-box level, liquid even w/outlet, no solids, no leaks in or out. Cleared some root intrusion.
Pump Chamber(locate on site pl ):
`a.ur'rijr.}.0 f•<6�Y ��y"v r"u'�i. ..U: r.vaa yJ.•Iwv•., .
Alarms in working order: ❑ Yes ❑ No*
Comments(note co ition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
"ccc�_Tm SuM.a'ft";a CGva,...n�.<gccJ OA s .opoP'�.d tt
N Commonwealth of Massachusetts:
v. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
123 Connemara Circle
Property Address
Owner Ownees.Name
information is required for every Hyannis MA 02601 07/03/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
1_J :a�cfi;iiiii' •'iCa - "f9uii:i►^lti'.
® leaching chambers number: (3) Cultec
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of,hydraulic failure, level of.gonding, damp soil condition of.
vegetation, etc.):
Med sand, no signs of hydraulic failure, no ponding, damp soil or abnormally lush vegetation. (3)
Cultec chambers in a 10'Wx25'Lx2'H configuration w/stone around.
Cesspools (cesspool must be pumped as pa f 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 constru on
Indicat(on of grounefwater inflow C .Yes U`No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Connemara Circle
.Property Address
�l!�Rc;:��R:�►<;�sJllincx.
Owner Owner's Name
information is Hyannis MA 02601 07/03/17
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):.
wraici�a�S con 6 Uuuui r: fix'
Dimensions
Depth of solids
Comments (note condition of soil signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
123 Connemara Circle
Property Address
Owner Owner s Name'
information is required for every Hyannis MA 02601 07/03/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at.least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where.public water"y..enters..the.-buildip.�.-Check-one-of:the.boXes,below.'
❑ hand-sketch in the area below
® drawing attached separately
. ` /"G
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
123 Connemara Circle
Property Address
Owner Owner's Name
information is required for every Hyannis MA 02601 07/03/17
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Surface water f..�
i
® Check cellar HI&
® Shallow wells
1Z
�Siii ias.Cta vc'N�i i .v i?iyi i yi.iiu�5u .viT' 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
® Checked with local Board of Health -explain:
Reviewed perc data from adjacent properties
❑ Checked with local excavators, installers -(attach documentation)
Reviewed USGS water resource and topographic maps
You must describe how you established the high ground water elevation:
Reviewed USGS topo and water resource maps. Reviewed as-built. Bottom SAS at 60". Groundwater
at 12' plus. SAS not to be found in high ground water.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
Commonweatth.of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°r 123 Connemara Circle
Property Address
Owner Ova&s Name
information is required for every Hyannis MA 02601 07/03/17
page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C, D, or E checked
.1r1aN CA .QuliiiV0"y v�oySTditi ryair .T�iTa G'fJ"Fiifi;dP� tL%""IZPY�iLCSPiifif�' l2'Ci' `
® .System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
Assessing.As-Built Cards Page 1 of 2
TO"OF BARNSTABLE
1. CONN(rMgAA �.0
LOCATION r�l(l�m(rC L SEWAGE#:�
AsSlrs OWS .&.LOT _ C>---
INSTALL S NAME&PHONE NO- ��J[�� �?D / 7 rL J
J --r—�.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type), (size) �L� O� �(:f)7
NO.Of BEDROOMS
BUILDER OR OWNER,
PERMTfDATE:_ '�" Iq- �I COMPLIANCE DATE: -aa--
^^�ipa7uicvti'i7sLln"t'l�tw�eU urc:
Maximum.Adjdi ied.Groundwater Table and Bottom of Leaching Facility Feet. ..
Private Water Supply Welland Leachiag.Facility (If any wells exist
on site br within,200 feet-of leachingYacility) Feet
Edge.of.W.etland aad Leaching Eacility(If any wetlands.exist
'within 300:feet of leaching facility) Feet.:
Furnished.by;
ql ` w G 9. r
z
i
g 1.
. o
http://www.townofbamstable.us/Assessing/FfMdisplay.asp?mappar=290137&seq=1 6/21/2017
TOWN OF BARNSTABLE �
C"NNE 4,� k Y
LOCATION - (2Or` j2-M C Nr SEWAGE # 1/4
VILLAGE 5 ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO..97r�
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) Je U�1�� (size) k
NO.OF BEDROOMS
BUILDER OR OWNER Y'" q-7
PERMITDATE: �" �.-'clCOMPLIANCE DATE: 'S - aa'-��
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) . Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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No. �. / ~ L y Fee $50 . 00
THE COMMONWEAIlTH O ASSACHUSETTS Entered in computer:
i es
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYication for Mi!5po�al *p5tem Construction i3ermit
Application for a Permit to Construct( )Repair( ?{j Upgrade( )Abandon( ) El Complete System O Individual Components
Location Address or Lot No. 1 2 3 Connemara C i r c 1 Owner's Name,Address and Tel.No. 7 7 5—8 4 0 5
Assessor's Map/Parcel �® Hyanns9 MA Mary Ann Collins
Installer's Name,Address,and Tel.No. ,�7 7 5—$] ]6 Designer's Name,Address and Tel.No.
WM E Robinson Sr Sdp.t Sr'v
PO Box 1089 , *Centerville, MA
Type of Building:-
Dwelling' No.of Bedrooms 2/3 Lot Size sq. ft. Garbage Grinder( n�)
Other Type-of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil sand
Nature of Repairs or Alterations(Answer when applicable) Title 5 Leaching system consisting
of a new D-Box, and three stonepacked .Cultex infiltrators . //" ,r 3rd
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued by this.Board of Health.
Signed t_ Date
Application Approved b Date
Application Disapproved for the following reasons
Permit No. � Date Issued -� ^
r
:....-fir� �rH.� •-•-1., �1^.w-+y .-.+ L`-7�`i...�.y.s.�.�M1't^..'�'.-sr•,,�{�...-.�-.-r�v'Y.++?..^.�ti��`TT►•�` -,. fit^ 1.�,.(;..:.�v^.�''"� .. Y'r�....�Tj-t k's�,�^�'�♦;�,,t i�..4.:
No. / ` l` !/ 3'��' • , q ! t f Fee $50.00
THE COMMONWEALTH'OF
- Entered in computer:
MASSACHUSETTS +'� l�
PUBLIC-HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS � es
y 2pplication for Migponl *pgtelm Congtruction Permit
Application for a Permit to Construct( )Repair( X)Upgrade( )Abandon( ) O Complete System` O Individual Components
Location Address or Lot No. 123 Connema r-a• Ci,k C 1 Owner's Name,Address and Tel.No. 7 7 5—8 4-0 5 ->
Assessor's Map/Parcel
Hyannis,. MA lylary Ann Collins 1
t
Installer's Name,Address,and Tel.No. 7 7 —8 7 7 6 Designer's Name,Address and Tel.No.
WM E Robinson Sr Sept 'Sry
PO Box 10..89, Centerville, MA ./''
Type of Building:'
Dwelling No.of Bedrooms 213 Lot S' _�```cc nn nn sq.ft. Garbage Grinder( nc)
Other' Type of Building No.
Persons' Showers( ) Cafeteria( )
4.
Other Fixtures
J.
Design Flow gallons per day. Calculated daily,flow' gallons.
Plan Date Number of beets I Revision Date
Title r
Size of Septic Tank Type of S.A.S.
Description of Soil sand
k
A
Nature of Repair or Alterations(Answer when applicable) (Title 5 Leaching system consisting_
of a new/, D-Box, and three stonepabked Cultex infiltrators.
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 provisions of Title 5 of the Environmental Code and not to place the system in operation until a ertifi- '
cate of,Compliance has been issued by thisBoarod of.Health.
r.a
Signed ' Date.S1_15_
Application Approved b Date..�a'��-%�'�`7
ti
Application Disapproved for the following reasons
Permit No. Dat I.J _
THE COMMONWEALTH OF MASSACHUSETTS
Collins BARNSTABLE, MASSACHUSETTS
Certificate of-Compliance
THIS.IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(. " ) Repaired (x )Upgraded( )
Abandoned( )by
at 123 Connwmara Circle, Hyannis, MA has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No e� dated
Installer Wm E Robinson Sr Spt. Srv. Designer
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
Date Inspector
O
No. �'----------------------------------------
$50.00
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
Collins Mi5pogal *pgtem Congtruction Permit'
Permission is hereby granted to Construct( )Repair( X)Upgrade( )Abandon( )
System located at 123 Connemara Circle
Hyannis, MA
Installer WM E Robinson Sr Septic Sry
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within,three years of the date of this it.
Date: Approved b V
NOTICE: This form is to be used for the repair of failed
septic systems only
CEIITIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS
' a
I,William E. Robinson. Sr.,hereby certify that the application for disposal works
construction permit sib ed by me dated concerning the
property located at 123 Connemara Circle, Hyannis, MA meets all
of the following criteria:
* here are no wetlands within 300 feet of the septic stem.
proposed A y
here are no private wells"within 150 feet of the proposed septic system.
�hc obseved groundwater table is 14 feet or greater below the bottom of the leaching facility.
"ere is no increase in flow and/or change in use proposed.
* There are no variances requested or needed.
SIGNED: !ti I V `�� DATES
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER 60
(Attach a sketch plan of the proposed system. Also if the licensed installer proposes a certification
plot plan,this plan should be submitted).
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r LJ�t �NSTABLETOFOFCONNE�4
OCATON �L SEWAGE#
VILLAGE l 5 ASSESSOR'S MAP& LOT
INSTALLER'S NAME&PHONE NO. 0 b1104
SEPT.0 TANK CAPACITY /C(mac/
LEACHING FAciLrrY: (type) ''� (size) l L �'�O� �C
NO.-OF BEDROOMS
BMDER OR OWNER ;zl
PERMUDATE: COMPLIANCE DATE:
:Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
o.n.site or within 200 feet of leaching facility) Feet
Edge'of Wetland and Leaching Facility.(ff any wetlands exist
::.;within 300 feet of leaching facility) Feet
Furnished by
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Commonwealth of Massachusetts /�FCfrr
Executive Office of Environmental Affairs JjJN
Department of 1
row 199I
Environmental Protection " � Q��AB(�
William F.Weld A
Gonrnor
Argeo Paul.Celluccl E hs
U.Goarnor Commlt>.lorrr
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A -
CERTIFICATION
Property Address: 123 Connemara Cir-,JHyannis Address of Owner. Mary Ann Collins
Date of Inspection: s- X ems— ! (If different)
Name of Inspector. W.E. Robinson SR
Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5-8 7 7 6
W.E. Robinson Septic Service
P.O. Box 1089 Centerville MA
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system:
_V Passes
_ Conditionally Passes
Needs Fuither Evaluation By the Local Approving Authority
Fails
Inspector's Signature: li(j Date: V2-s /
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(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 Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
s ,
INSPECTION SUMMARY: '
Check A, B,.C,or D: +,
A] SYSTEM PASSES:
1 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are indicated below.
B SYSTEM CONDITIONALLY PASSES: i
One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair;passes
inspection.
^rJ ti
Indira yes, no,or not determined(Y,N,or ND). Describe basis of determination in all instances: If"not determined",explain why not) `s+r
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiitration,.or tank failure is'
imminent. The system will pass inspection if the existing septic tank is replaced with a ponforming septic tank ae approved'!.(k',
by the Board of Health.
(re ised 11/03/95) 1
One Winter Street • Boston,Massachusetts 02106 • FAX(617)SWID49 • Telephone(617)202-SS00
i,Printed on Recycled Paper
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 123Connemara Cir, Hyannis
Owner. Mary Ann Collins
Date of Inspection: 2_cl
1. ]SYSTEM CONDITIONALLYO� PASSES(continued)
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipes)
or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of
Health):
broken pipe(s)are replaced
obstruction is removed
distribution box is levelled or replaced
The system!equip pumping more than four 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
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 the
public health,safety and the environment.
SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A
MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND 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 APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water
supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm.
9) OTHER
(revised 11/03/95) 2
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(oontinued)
Property Addreas: 1 2 3 Connemara Ci r, Hyannis
Owner. Mary Ann Collins
Date of Inspection: `L-4
DI STEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for
his determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the
Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
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. If the well has been analyzed to be acceptable,attach copy of well water analysis for
eoliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
EI LARGE YSTEM FAILS:
Th following criteria apply to large systems in addition to the criteria above:
system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public
and safety and the environment because one or more of the following conditions exist:
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 U of a public
water supply well)
The owner or rator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements 314 CMR.5.00 and 6.00. Please consult the local regional office of the Department for further information..
(revised 11/03/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Addmm 123 Connemara CIr, Hyannis
owner. Mary Ann Collins
Date of Inspeotioa: :5_� _�3 ,]
Check if the,following have been done:
—✓Polumping information was requested of the owner,occupant,and Board of Health.
_L44one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
�As built plans have been obtained and examined. Note if they are not available with N/A.
facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non-sanitary or industrial waste flow
,� The site was inspected for signs of breakout.
ZAll system components,excluding the Soil Absorption System, have been located on the site.
_&/I'he septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected for condition of baffles or
tees, material of construction,dimensions,depth of liquid,depth of sludge, depth of scum.
"The size and location of the Soil Absorption System on the site has been determined based on existing information or
_�ap ted by non-intrusive methods.
ty owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub.
Surface Disposal System.
(revised 11/03/95) 4
I,
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
property Address: 123 Connemara Cir, Hyannis
Owner. Mary Ann Collins
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:yfp gallons
Number of bedrooms: 3
Number of current residents:
Garbage grinder(yes or no): o _
Laundry connected to system(yes or no):X!�-s
Seasonal use(yea or no): A- v
Water meter readings,if available: 1995 7600 c u f t
199h 7h00 ff-
i
Last date of occupancy:-!C—;,2--4 7
COMMERCIAL/INDUSTRIAL:
Type of establishment:
Design flow:_gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)_
Non-sanitary waste discharged to the Title 5 system: (yes or no)_
Water meter readings, if available:
Lest date of occupancy:
OTHER:(Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING,RECORDS egad source of information:
System pumped as part of inspection: (yes or no)_
If yes,'volume pumped: gallons
Reason for pumping:
TYPE OIe SYSTEM
Septic tank/distribution box/soil absorption system
Single Cesspool
Overflow cesspool
Privy
Shared system(yea or no) (if yes,attach previous inspection records, if any)
Other(explain)
APPROXIMATE AGE of all components,date installed(if known)and source of information: .s Gov J;,-al ^Z Z-
e
Sewage odors detected when arriving at the site: (_yes or no) C)
(revised 11/03/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(oontinued)
PropertyAddrem 123 Connemata Cir, Hyannis
Owner. Mary Ann Collins
Date of Inspection: s•-�-2^g 7
SEPTIC TANK
(locate on site plan)
Depth below grade:,
Material of construction:%ncrete_metal_FRP_other{e:plaia)
Dimensions: k
Sludge depth;
Distance from top of sludge to bottom of outlet tee or battle: ��O
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:-
Comments:
(recommendation for pumping,condition of inlet�?d outlet tees or baffles,depth of liquid level in relation to outlet invert,structural fate,
evidence of leakage,etc.) a �' C�6 ` pn dc.
(i E TRAP•._
(locate on site plan)
Depth low grade:
Mete ' of construction:_concrete_metal_FRP--other(explain)
ions:
thickness:
from top of scum to top of outlet tee or bate:
Distaa from bottom of scum to bottom of outlet tee or baffle:
Comm ts:
(reco endation for pumping,condition of inlet and outlet tees.or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evide ce of leakage,etc.)
(revised 11/03/95) 6
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SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 1 2 3 Connemara Cir,, Hyannis
Owner. Mary Ann Collins
Date of Inspection: S^,Z 2_
TIG OR HOLDING TANK_
(1— site plan)
Depth be grade:
Material construction:_concrete_metal_FRP_other(ezplain) -
no:
Ca ty: gallons
Design ow: gallons/day
Alarm 1 1:
Comore ts:
(conditi n of inlet tee,condition of alarm and float switches,etc.)
DISTRIBUTION BOX: '
(locate on site plan) .
Depth of liquid level above outlet invert:_
Comments:
(note if level and diqtoution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
ra e",
P P CHAMBER:_
(10 on site plan)
Pumps working order:(yes or no)
(note co tion of pump chamber,condition of pumps and appurtenances,etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 123 Connemara CIr, Hyannis
Owner. Mary Ann Collins
Date of Inspection: 5—A 2 -91
SOIL ABSORPTION SYSTEM(SAS):1
(locate on site plan,if possible;excavation not required,but may be appra umated by non-intrusive methods)
If not determined to be present,explain:
Type:
leaching pits, number:.l
leaching chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields, number, dimensions:
overflow cesspool,number:
Comments: (note condition of soil,or of ydraulic facture, le el of ponding,condition of vegetation,etc.)
S r Px id�c c Let � �,
C POOLS:
(lots on site plan)
Numbs and configuration:
Depth- p of liquid to inlet invert:
Depth o solids layer.
Depth o scum layer:
ns of cesspool: i
Mate ' of construction:
Indica ' n of groundwater:
inflow(cesspool must be pumped as part of inspection)
Commen : (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.)
PRIVY _
(lots on site plan)
Ma of construction: Dimensions:
Depth f solids:
Comme to:(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
(revised 11/03/95), g
k.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
PropertyAddrese: 123 Connemara Cir, Hyannis
Owner. Mary Ann Collins
Date of Inspection: ,.;7-,7_- 9 7
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' �-
1
4
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ti S,a vg �
F YZ0>~,
DEPTH TO GROUNDWATER
Depth to groundwater: ,J a J feet
method of determination or approximation: L 3 ) l^d�'L° —:z
(revised 11/03/95) 9
.................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 0 HEALTH_
..
..........OF..... 0 ....464?. . ......... ........ ........
Appliration for Diopmal Marks Tonstradion rumit
Application is hereby made for a Permit to Construct (tl�or Repair an Individual Sewage Disposal
Syste,2,at:
--------------------------------------------------------------------
. ......... ...... ......
Ell '�on,Address
..:........................................ ...... :. .......................................
or
7
ner Address
----------- ............................ Inst.aller ----------------- ------------------------------------ ---Address"'*....................I•
%—, ......
Type of Buillk Size Lot----i..c' vU�........Sq. feet
r........
U
Dwelling—No. of Bedrooms...........................................Expansion Attic Garbage Grinder
aOther—Type of Building ............................ No. of persons._._....._...___.........._. Showers Cafeteria
Other, tures .......................................................................................................
.......... .......................
Design Flow.......%.................. gallons per person per day. Total daily flow.......... ....................:...gallons...'
Septic Tank—Liquid capacit,y�,!..� ,.,nl
......gallons Length................ Width.._............. Diameter................. Depth....__...__.
Disposal Trench—No........... ' Wi 'i.................... Total Length.................... Total leaching are;�,..................sq. ft.
Seepage Pit No..Id.0,1).. Diamet.........*............ Depth below inlet.................... Total leaching area'.\,.........J..sq. f t.
Z Other Distribution box Dosing tank
Percolation Test Results Performed by...........................................................;.............. Date------------------......................
Test Pit No. 1..........:.....minutes per inch Depth of Test Pit_.___......_..__._._ Depth ...'th to ground water............i..
.........
�q Test Pit No. 2................minutes per inch Depth of Test Pit...................... Depth to ground water....................\1
P4 .......................................................................................................................................................:.........
0 Description of Soil------------------ ...........................
----------------A----;?..............
.... . ..........................................................................
--------------------------------- ---------------------- .................................................................................................................................................................. ...................
U Nature of Repairs or Alterations—Answer when applicable.__.............................................................................................
........................................................................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the.system in
operation until a Certificate of Compliance has bee issued by the board of health.
SignedtfJK.. v............................. .............................
D
Application Approved By.._....- -- -----------
Date
Application Disapproved for the following reasons:................................... ..................................................................
............................................................:............................................................................................................................................
Date
PermitNo......................................................... Issued........................................................
Date
-------------------------------------------- ------------
No...��~ .. .... Fps... ..............
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OFj HEALTH
..-..-----.OF.......... .............. . . ---___`.._.._.
ltovviial Marks Tonst.rurti,an runtit
Application is-.hereb3fGade for a Permit to Construct (kror Repair ( ) an Individual Sewage Disposal
Syst at: U.
�.. '.:__....-
_..
o
................................:....
rLion Address r4.. n............................................ .......... .......--4d .. ..... ......................•-
er ..................... ne Address
... .. •-�-- . ............._.- _..---.....------..........._..........----
Installer Address
Q Type of Building. Size Lot__..V ........... t3'c. feet
i� *
Dwelling—No. of Bedrooms........ _,_............................Expansion Attic ( Garbage Grinder
Other—Type-of Building ____________________________ No. of persons............................ Showers Cafeteria ( )
Othe fixtures •---------•----•-•--•-•--•------ Cf
WDesign Flow....... ________________________J_ ��`j�allons per person per day. Total daily flow_.._._..t'1__°_`�______..__._._-_.____.__.._gallons.
WSeptic Tank—I:igtaid capacity./-'^'gallons Length________________ Width_______._.____.. Diameter................ Depth................
Disposal Trench—No. ..........pp,. 'Vidtj-t.................... Total Length.................... Total leaching area...................sq. ft.
-Seepage Pit No._/ -Q0_•. Diamet r__//_'`_.._______________ Depth below inlet..................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
Test Pit 1V0:{2................minutes per inch . Depth of Test Pit.................... Depth to ground water........................
x Description of Soil....................
._.._. _ _.•< -. ---- "
U --•-••----------------•--............................................................................
'
W ?
V Nature of Repairs or Alterations Answer when applicable...............................................................................................
------------------------ =--=--.......
_....................................
-----------------
---•--------------------------------------------
•............................
••..............
Agreement:
The undersigned agrees, to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a C ertificate•of Compliance;has bee ssu9d by,the board of lealthx-
°
Signed.-- ............................... --------••------
Date
Application Approved By _... -
L..
Application Disapproved for the following reasons:_._____:................... •--•---••-••---• ... -•----• ------
Date
PermitNo.............................-:..---•------.....-______..... Issued._._.:t................................................
� .....a'-..< Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
OF.. ..14-
... .
TH S I TO CERTIFY, at the Individual Sewage Disposal System constructed Repaired ( )
by..... --••-•,-. •: to ..
at... - = . -- . -•- •---•.................•••---•---•---........._•---••-•-.._...____
has een i stalled in accordance with t e pro Is
o�'Article he ate Sanitary Code as described in the
P Y
application for Disposal Works Construction Permit No. _+.._____ .}..................... dated----- .__ .,_� .._r_�.__.__._...
THE ISSUANCE OF THIS CERTIFICATE SHALL AT BE CONSTRUED AS X► 6U TkE �HA'T THE
SYSTEM WJ IL FUNCTION SATISFACTORY.
DATE......E ..�. �......Z;i ........................................ Inspector.. L .
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF kid ALTH
N .. J1
........0F. ...
04 _....
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MOP ,15 1 arks Tlanstrurtilan rrrntit '�,
f Permission is hereby gran 46ewe
�/�, • -- •••-•••........ ..........to Construct or"'Repair ( an, pd1vt ual S �spo I s
atNcL-- IJ`% ...., .•- - �" ••--•- .,,.;............................
- �t.{t-
as shown on the pplication for Disposal Works ConstrucfiRw-"Pernr1it U6. ated
1` pf,Sy ,
sDATE.....-••-- ...................................................................
FORM 125 OBB & WARREN. INC.. PUBLISHERS f
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CERTFF I E D- PL OT P L A N
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SCALE- DATE 91AOf
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R't 1=.E il` C N' C E: BEING Z- o T 62. A S S f✓O wn/
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It.-H.E' REBY CERTIFY TH- AT- THE BUILDIMG REG. LAND SURVEVV'R-
SKOWN ON - THIS PL-AN. IS LOCATED ON
.TF E- GROUND AS SHOWN HEREON AND
T-.MAT ti /0Q06S CONFORM TO THE OF��' I
_tANLNG BY - LAWS OF THE TOWN OF
1�3fiF?/VSTABLE WHEN CONSTRUCTED. I.
&..A-RMS•TAIFFIL1✓ SURVEY C0NSU LTA NI-Sj' 1NC., fe
_ WESY. 7ARM-1Ourei,. MASS.. _ y � su��
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