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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Conemara Circle
Property Address
Kristen Hyde
Owner Owner's Name
information is H annis MA 02601 April 23, 2009
required for y P
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way.
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector: I J✓ �/
only the tab key
to move your Patrick M. O'Connell
cursor-do not Name of Inspector
use the return
key. Septic Inspection Services Co.
Company Name
189 Cammett Road
Company Address
Marstons Mills MA 02648 _
City/Town State Zip Code
508-428-1779 S1 12855
Telephone Number License Number
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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
0—
CA R April 23, 2009 1
In ector'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.
9
0M9 Hyde.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Conemara Circle .
Property Address
Kristen Hyde
Owner Owner's Name
information is Hyannis MA 02601 Aril 23 2009
required for y P
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
Tank is not in need of pumping at this time, leaching chambers have no signs of hydraulic 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.
*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:
f sewage backup or break out or high static water level in the distribution box due
❑ Observation o s g p g
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
09-69 Hyde.doc-08/06 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 153 Conemara Circle
Property Address
Kristen Hyde
Owner Owner's Name
information is
required for Hyannis MA 02601 April 23, 2009
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:
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f
C) Further Evaluation is Required by the Board of Health: t
❑ 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 F ''
15.303(1)(b)that the system is not functioning in a manner which will protect public health,. a
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 4
supply well
09-69 Hyde.doc•08f06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 }
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM. 153 Conemara Circle
Property Address
Kristen Hyde
Owner Owner's Name
information is Hyannis MA 02601
required for y April 23, 2009
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 over
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
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.
09-69 Hyde.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 15
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Conemara Circle
Property Address
Kristen Hyde
Owner Owner's Name
information is required for y H annis MA 02601 April 23, 2009
every page. Cityrrown 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.
t
09-69 Hyde.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Conemara Circle
Property Address
Kristen Hyde
Owner Owner's Name
information is Hyannis MA 02601 April 23, 2009
required for y
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?
® El 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?
. f
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)]
09-69 Hyde.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of f 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Conemara Circle
Property Address
Kristen Hyde
Owner Owner's Name
information is Hyannis MA 02601 Aril 23, 2009
required for Y P
every page. CitylTown State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
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
Last date of occupancy: November 2008
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:
i Last date of occupancy/use: Date
Other(describe):
09-69 Hyde.doc-08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 o1 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Conemara Circle
Property Address
Kristen Hyde
Owner Owner's Name
information is required for Hyannis MA 02601 April 23, 2009
_
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information: None
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known) and source of information: + .
Compliance date 9/15/99 ;
k Were sewage odors detected when arriving at the site? ❑ Yes ®- No
.09-69 Hyde.doc-08f06. 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
153 Conemara Circle
Property Address
Kristen Hyde
Owner Owner's Name
information is Hyannis MA 02601 Aril 23, 2009
required for y p
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
1'
Depth below grade: feet
Material of construction:
❑ cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Septic Tank (locate on site plan):
Depth below grade: 1 '
feet
Material of construction:
®concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal,list age: years
. I
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
--------------------------------------- ----------------------------------------------------------------------------------
Dimensions: 8.5' long x 5.2'wide- 1000 gal.
Sludge depth: 3
Distance from top of sludge to bottom of outlet tee or baffle
27"
2„
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
12"
How were dimensions determined? Measured
09-69 Hyde.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
i
153 Conemara Circle
Property Address
Kristen Hyde
Owner Owner's Name
information is required for Hyannis MA 02601 Ap rll 23, 2009
_
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Liquid level was found at bottom of outlet invert, tees intact and clear. Tank is not in need of pumping
at this time.
Grease Trap (locate on site plan):
r
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:
Y
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
09.69 Hyde.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 15 t
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 153 Conemara Circle
Property Address
Kristen Hyde
Owner Owner's Name
information is required for y H annis MA 02601 April 23, 2009
every page. Cityrrown 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):
0 Depth of liquid level above outlet invert
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.): r
No solids or high stains present. Liquid level at bottom of outlet pipes.
Pump`Chamber(locate on site planJI
's
Pumps in working order: ❑ Yes ❑ No
Alarms to working order: ❑ Yes ❑ No t
09-69 Hyde.doc•08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
w 153 Conemara Circle
Property Address
Kristen Hyde
Owner Owner's Name
information is H annis MA 02601
required for y _ April 23, 2009
every page: Cityfrown 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:
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Type:
❑ leaching pits number:
® leaching chambers number: Two 500 gal {
drywells.
❑ 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
+f vegetation, etc.):
Access covers are located under shed, stone and soils were probed and found no evidence of
saturation or hydraulic failure.
i
09-69 Hyde.doc-08106 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Conemara Circle
Property Address
Kristen Hyde
Owner Owner's Name
information is Hyannis MA 02601 A rll 23, 2009
required for y _ P
every page. City/town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
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09b9 Hyde.doc-08f06 Title 5 Official Inspection Form:'Subsurface Sewage Disposal System-Page 13 of 15
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commonwealth of Massachusetts
T 1le 5 Official Inspection Fo' yrm
it
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Conemara Circle
Property Address
Kristen Hyde
Owner Owner's Name
information is Hyannis MA 02601 April 23, 2009
required for State Zip Code Date of Inspection
every page. City/Town
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.
Water
Service
21 2
22 3
29
39
• <�N, Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
153 Conemara Circle
Property Address
Kristen Hyde
Owner Owner's Name
information is Hyannis MA 02601 April 23, 2009
required for Y _ P
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
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' Estimated depth to ground water: 20'feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: '
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health -explain:
❑ Checked with local excavators,installers - (attach documentation)
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® Accessed USGS database-explain:
USGS topo map and town GIS
You must describe how you established the high ground water elevation:
Town groundwater contour map shows water below el. 20 and topo map shows property at el. 40.
09-69 Hyde.doc•08/06 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 15
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CO-MMO.N-WEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
=,.�_ DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE'�NZNTER STREET. BOSTON ALL 02108 (617) 292-5500
TRUDY CORE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 153 Connemara Circle Name of Owner Sam R i tker
Hyannis MA Address of Owner:
Date of Inspection: 9`—f S`
Name of Inspector:(Please Print)
1 am a DEP approved system inspector pursuant to Section;15.340 of Title 5(310 CMR 15.000)
ConpanyName: Wm. E. Robinson Septic Service
Mailing Address: P 0 Box 1089, Centerville , MA
Telephone Number: 7 7 5-R (�
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 sewa a disposal systems. The system:
G/Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fails
Inspector's Signature: 4 V Date:
The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)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.
NOTES AND COMMENTS
COVE -
�� OCT 15 1999
TOWN OF BAMSTABLE
HEALTH DEPT.
revised •9/2/98 Page Iof11
;. ✓rmted on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM t
PART A
CERTIFICATION (continued)
Imp"Address: 153 Connemara Circle , Hyannis
J- Sam Ritker
Date of Inspection:
INSPECTION SUMMARY: Check T B, C, o/ D:
A. SYSTEM PASSES:
V/I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 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
ompletion of the replacement or repair, as approved by the Board of Health, will pass.
Indicate y , no, or not determined(Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked,structurally unsound, shows substantial infiltration or exfiltration, or tank
failure is imminent. The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
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_ Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
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 required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if(with approval of the Boarc of Health):
broken pipe(s) are replaced
obstruction is removed
revised 9/2/98 Page 2of11
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 163 Connemara Circle , Hyannis
Owner: Sam R itker
Date of Inspection:
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
C nditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
p lic health, safety and the environment.
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1) SY TEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303(1)(b)THAT THE SYSTEM
IS OT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
_ Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid).
3) OTHER
I
revised 9/2/98 Page 3or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 153 Connemara Circle , Hyannis
DWnef: Sam Ritker
Date of Inspection: 9—1,5-,Q9
D. S TEM FAILS:
You must'ndicate either "Yes" or "No to each of the following:
I ave dermined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
d terminatiteon is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes N
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 ir.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
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E. LAR E SYSTEM FAILS:
You must ndicate either "Yes" or "No" to each of the following:
he following criteria apply to large systems in addition to the criteria above:
e 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
h alth and safety and the environment because cne or more of the following conditions exist:
Yes o
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)
The o ner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional
j office f the Department for further information.
revised 9/2/98 Page 4of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
F .
Prop"Address:153 Connemara Circle , .Hyannis ,
Owner: Sam R itker
Date of Inspection: ,:rS T g
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health.
_ None of the system components have been pumped.for at least two weeks and-the system has been-receiving tw rnal 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 NIA.
_ The 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.
_ All system components, excluding the Soil Absorption System, have been located on the site.
The 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. For example, Plan at B.O.H..
JZ/ _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
/ [15.302(3)(b))
✓ - _ The facility owner (and occupants,if different from owner) were provided with information on the proper.maintenaaco-0f
SubSurface Disposal Systems.
revised 9/2/98 Page 5ofII
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
w
PART C
SYSTEM INFORMATION
Property Address: 153 Connemara Circle., Hyannis
Owner: Sam R it ker
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL:
Design flow:!Y VO g.p.d./bedro m.
Number of bedrooms(design): Number of bedrooms(actual):,?
Total DESIGN flow 4/` )
Number of,current residents:
Garbage grinder(yes or no):6cp
Laundry(separate system) (yes or no):Ad� If yes, separate.inspection required
Laundry system inspected yes or no)
Seasonal use (yes or no):_
Water meter readings, if available (last two year's usage(gpd): 1998 138, 000 gal.
Sump Pump(yes or no): " 1997 NA new meter
Last date of occupancy:�1S 9 7
COMME-RCIAL/INDUSTRIAL:
Type of a tablishment:
Design flo qpd ( Based on 15.203)
Basis of d sign flow
Grease tra present: (yes or no)_
Industrial aste Holding Tank present: (yes or no)_
Non-sanit ry waste discharged to the Title 5 system: (yes or no)_
Water me er readings, if available:
Last date of occupancy:
OTHE (Describe)
Last da occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no:
If yes, volume pumped: . gallons
Reason for pumping:
TYPE 0 YSTEM
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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
r CC
APPROXIMATE AGE of all components, date installed(if known) and source of information: .-R e-V°a c r
Sewage odors detected when arriving at the site: (yes or r.o) b o ' Y!r R `39 y" 9
revised 9/2/98 Page 6of11
i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'►op"Address: 153 Connemara Circle , Hyannis ,
Owner: Sam ltk�+er
Date of Inspection: �fJ~4
BUIL ING SEWER:
(Local on site plan)
Depth k elow grade:_
Materia of construction:_cast iron_40 PVC_other (explain)
Distan from private water supply well or suction line
Diame r
Com ents: (condition of joints, venting, evidence of leakage,-etc.)
SEPTIC TANK:_
(locate on site plan) ` I
Depth below grade:
Material of construction: concrete_metal_Fiberglass _Polyethylene_other(explain)
If tank is metal,list age_ .Is.age confirmed by Certificate of Compliance_(Yes/No)
Dimensions: �i �✓
Sludge depth: O A'
Distance from top of sludge to bottom of outlet tee or.baffle:-�ti
Scum thickness: 0 1
Distance from top of scum to top of outlet tee or baffle: F ,i
Distance from bottom of scum to bottom.34outlet tee or baffle:,�1
How dimensions were determined: l't'A.- 4 it 1<
'omments:
(recommendation for pumping, con ition of inlet and outle tees or baffles, depth of liqui level in relati n to outlet invert, structural integrit
evidence of leakage, etc.) �e ��C J r0✓�' L t� v�5 t .d /—�IL;1< .1. G9 V 1 Lei 1
GREASE P:
(locate on site Ian)
Depth below gra e:_
Material of const uction:_concrete_metal_Fiberglass _Polyethylene_other(explain)
Dimensions:
Scum thickness:
Distance from to of scum to top of outlet tee or baffle:
Distance from bo om of scum to bottom of outlet tee or baffle:
Date of last pum ing:
Comments:
(recommendati n for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of le kegs,at
I
revised 9/2/98 Page 7of11
t
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
'roperty Address: 153 Connemara Circle , Hyannis ,
Owner: Sam R itker
Date of Inspection:
TIGH OR HOLDING TANK: (Tank must be pumped prior to, or at time of, inspection)
(locate n site plan)
Depth be ow grade:_
Material f construction:_concrete_metal_Fiberglass_Polyethylene_other(explain)
Dimensio s:
Capacity: gallons
Design fl gallons/day
Alarm pre ent
Alarm lev I: Alarm in working order: Yes_ N-o_
Date of p evious pumping:
Commen s:
(conditi of inlet tee, condition of alarm and float switches,etc.)
I
DISTRIBUTION BOX: 30
(locate on site plan)
Depth of liquid level above outlet invert:_
Comments:
(note if level and distribution is equal, evidence of solids carryov r, evidence of eakage into or out of box, etc.) -
A 4.21
PUMP CHA BER:_
(locate on si a plan)
Pumps in w rking order: (Yes or No)
Alarms in orking order(Yes or No)
Comment :
(note co ition of pump chamber, condition of pumps and appurtenances,etc.)
revised 9/2/98 Page 8ofII
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
'SYSTEM INFORMATION(continued)
4operty ddress: 153 Connemara Circle , Hyannis :
owner: Sam Ritker
Date of Inspection:
SOIL ABSORPTION SYSTEM(SAS):_
(locate on site plan, if possible; excavation not required, location may be approximated by non-intrusive methods)
If not located, explain:
Type:
leaching pits, number:_
leaching chambers, number:.
leaching galleries, number:_
leaching trenches, number, length:
leaching fields, number, dimensions:
overflow cesspool, number:_
Alternative system:
Name of Technology:
Comments:
(note ondition o `soiilsigns of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.)
CESSPOOLS:_
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
lepth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must b pumped as part of inspection)
Comments:
(note condition of soil, signs f 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, si s of hydraulic failure, level of ponding, condition of vegetation, etc.)
revised 9/2/98 Page 9of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Nop"Address: 153 Connemara Circle, Hyannis
)wrw: Sam R itker
Jate of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
A
r
revised 9/2/98 Page 10ofII
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(coftnued)
rop"Address: 153 Connemara Circle , Hyannis
Owner: Sam R itker
Date of Inspection: Q
NRCS Report name
Soil Type_
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater jo_- Feet
Please indicate all the methods used to determine High Groundwater Elevation:
/Obtained from Design Plans on record
Y Observed Site (Abutting property, observation hole, basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe
how
you established the High yGroundwater Elevation. (Must be completed)
revised 9/2/98 Page 11 of11
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 153 CONNEMARA CIRCLE HYANNIS �� � 3 3 L 6 9
Name of Owner SAM RICKER d®
Address of Owner: SAME
Date of Inspection: 7126/99
Name of Inspector:(Please Print)JOHN GRACI t®
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) AV G 5 1999
1 for
Company Name: n/a
Mailing Address: n/a HfgITMLIT
AB(F
Telephone Number: n/a
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:
Passes The inpection Is based on criteria defined in Title V
Conditionally Passes code 310 CMR 15.303.My findings are of how the system is
_ Needs Further Eval all By the Local Approving Authority performing at the time of the Inspection.My Inspection does
X Fails not Imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: Date:7/27/99
The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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.
NOTES AND COMMENTS
THE SYSTEM FAILS TITLE V INSPECTION. THE LEACH PIT WAS FULL OVER THE PIPE AT THE TIME OF THE INSPECTION.THERE WAS NO
VISABLE LEACHING LEFT.
revised 9/2/98 Page 1 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 163 CONNEMARA CIRCLE HYANNIS
Owner: SAM RICKER
Date of Inspection:7/26/99
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described In 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
n/a
B. SYSTEM CONDITIONALLY PASSES:
n(a 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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
n(a Sewage backup or breakout or high static water level observed In the distribution box is due to broken or obstructed pipe(s)
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 ;
nta The system required 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
revised 9/2/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 153 CONNEMARA CIRCLE HYANNIS
Owner: SAM RICKER
Date of Inspection:7/26/99
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.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 16.303(1)(b)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 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 HEALTHAND SAFETY AND THE 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 soil absorption system and the SAS is within'a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the,SAS is within 50 feet of a private water supply well,
The system has a septic tank and soil absorption system and the SAS 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,Method used to determine distance n(a_(approximation not valid).
3) OTHER
n&
t
revised 9/2/98 Page 3 of 11
i
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A '
CERTIFICATION(continued)
Property Address: 163 CONNEMARA CIRCLE HYANNIS
Owner:• SAM RICKER
Date of Inspection:7/26/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
X I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times In the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped nLa.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,Is in Hydraulic Failure.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The 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 health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 163 CONNEMARA CIRCLE HYANNIS
Owner: SAM RICKER
Date of Inspection:7/26/99
Check if the following have been done:You must indicate either'Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None 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.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The 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:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 9/2/98 Page 5 of 11'
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 153 CONNEMARA CIRCLE HYANNIS
Owner: SAM RICKER
Date of Inspection:7/26/99
FLOW CONDITIONS
RESIDENTIAL;
Design flow:-M g.p.d./bedroom
Number of bedrooms(design): 2 Number of bedrooms(actual):2
Total DESIGN flow: 22t2
Number of current residents:.a
Garbage grinder(yes or no):NO
Laundry(separate system)(yes or no): NQ If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):JLQ
Water meter readings,if available(last two year's usage(gpd): n/a
Sump Pump(yes or no): NO
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow: n/a gpd(Based on 15.203)
Basis of design flow: n/A
Grease trap present:(yes or no):DLO
Industrial Waste Holding Tank present:(yes or no): NQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):NQ
Water meter readings.if available:n/a
Last date of occupancy: n/a
OTHER: (Describe)
Wa
Last date of occupancy: n/a
GENERAL INFORMATION
PUMPING RECORDS and source of information:
THE Y T M WAS A T PUMPED 6 YEARS 01 D
System pumped as part of inspection:(yes or no):NQ
If yes,volume pumped n/a_ gallons
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous`inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: n/a
APPROXIMATE AGE of all components,date installed(if known)and source of information:
THE SYSTEM IS 25 YEARS OLD.
Sewage odors detected when arriving at the site:(yes or no) ND
i
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 163 CONNEMARA CIRCLE HYANNIS
Owner: SAM RICKER
Date of Inspection:7/26/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: 14"
Material of construction:_ cast iron _ 40 PVC X other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nLa
Comments: (condition of joints,venting,evidence of leakage,etc.)
nLa
SEPTIC TANK: X
(locate on site plan)
Depth below grade: IC
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nLa .
If tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): NO
Wa
Dimensions: L 8'6"H 6'7"W 4'10"
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:.
Scum thickness:
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: n&
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
THE SEPTIC TANK NEEDS NEW OUTLET TEE,RECOMMEND PUMPING NOW AND THEN MAINTAINED EVERY TWO YEARS-
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
Wa
Dimensions: nLa
Scum thickness: n&
Distance from top of scum to top of outlet tee or baffle:i3La
Distance from bottom of scum to bottom of outlet tee or baffle nLa
Date of last pumping: n&
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
n&
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 153 CONNEMARA CIRCLE HYANNIS
Owner: SAM RICKER
Date of Inspection:7126/99
TIGHT OR HOLDING TANK: NO (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nLa
Material of construction:_ concrete_ metal_ Fiberglass_Polyethylene_ other(explain)
nLa
Dimensions: Wa
Capacity: Wa gallons
Design flow: nLa gallons/day
Alarm present: NYQ
Alarm level:jiL& Alarm in working order:Yes—No—: MQ
Date of previous pumping: Wa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
Wa
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:Wit
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP CHAMBER: MQ
(locate on site plan)
Pumps in working order:(Yes or No): MQ
Alarms in working order(Yes or No): MQ
i Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nLa
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 153 CONNEMARA CIRCLE HYANNIS
Owner: SAM RICKER
Date of Inspection:7/26/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: jiLa
leaching galleries,number: jaLa
leaching trenches,number,length: n&
leaching fields,number,dimensions: n&
overflow cesspool,number: nLa
Alternative system: n&
Name of Technology: ji&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE LEACH PIT IS PAST THE EFFECTIVE DEPTH OF LEACHING- THE LIQUID LEVEL IS OVER THE PIPE,THERE WAS NO VISA13LE LEACHING
LEFT,
. CESSPOOLS: _
(locate on site plan)
Number and configuration: nLa
Depth-top of liquid to inlet invert: nLa
Depth of solids layer: n&
Depth of scum layer. nla
Dimensions of cesspool: n/a
Materials of construction: Wa
Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
PRIVY: _
(locate on site plan)
Materials of construction:n& Dimensions:n&
Depth of solids: n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
revised 9/2/98 Page 9 of 11
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 163 CONNEMARA CIRCLE HYANNIS
Owner: SAM RICKER
Date of Inspection:7/26199
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
Ad 1
0C A-9
(� 31
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 153 CONNEMARA CIRCLE HYANNIS
Owner: SAM RICKER
Date of Inspection:7/26/99
NRCS Report name: r&
Soil Type: nla
Typical depth to groundwater: n&
USGS Date website visited: n&
Observation Wells checked: NQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 10 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
- Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
X Used USGS Data
I
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS-10+FEET
revised 9/2198 Page 11 of 11
? c+TOWN OF B E
LOCATION 138 SEWAGE #
VILLAGE ASSESSOR'S MAP& LOT��_+ �—
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) j✓1#- f I ne (size)
NO.OF BEDROOMS
BUILDER OR OWNER `
i
PERMIT DATE: OMPLIANCE DATE:
Separation Distance Between the:
1
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 i
within 300 feet of leaching facility) Feet
Furnished by �J�QG
I
e.v
F-f
T1
a7 S.•
� n
q � �
Xk
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAI AFFAIRS John Graci
DEPARTMENT OF ENVIRONMENTAL PROTECTION DEP Title V Septic Inspector
ONE WINTER STREET BOSTON MA 02108(617)292-3500 P.O.Box 2119
TeaTicket,Ma.
(508)564-6813
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B.STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address: 138 RICHARDSONS RD. CENTERVILLE �a\O <
Name of Owner MARY MCDONOUGH
Address of Owner: 97 EMERALD LANE MARSTONS MILLS MA.02648
Date of Inspection: 7/26/99
Name of Inspector:(Please Print)JOHN GRACI
1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000)
Company Name: n/a
Mailing Address: n/a
Telephone Number: n/a
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:
X Passes The Inpection Is based on criteria defined In Title V
Conditionally Passes code 310 CMR 15.303,My findings are of how the system Is
Needs Further Evalua"o By the Local Approving Authority performing at the time of the Inspection.My Inspection does
_ Fails not Imply any warranty or guarantee of the longgevity of the
septic system and any of Its components useful life.
Inspector's Signature: Date:7/27/99
The System Inspector shall ubmit a copy of this inspection report to the Approving Authority(Board of Health or DEP)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.
NOTES AND COMMENTS
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING NOW AND THEN MAINTAINED EVERY ONE TO TWO YEARS.
revised 9/2/98 Page 1 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 138 RICHARDSONS RD.CENTERVILLE
Owner: MARY MCDONOUGH
Date of Inspection:7126/99
INSPECTION SUMMARY: Check A, B, C, or D.
A. SYSTEM PASSES:
I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist.Any failure criteria not evaluated
are indicated below.
COMMENTS:
System passes Title V inspection
B. SYSTEM CONDITIONALLY PASSES:
nLa 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.
Indicate yes,no,or not determined(Y,N,or ND).Describe basis of determination in all instances.If"not determined",explain why not.
nLa The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or
the septic tank,whether or not metal,Is cracked,structurally unsound,shows substantial infiltration or exfiltration,or tank
failure is imminent.The system will pass inspection If the existing septic tank is replaced with a complying septic tank as
approved by the Board of Health.
nLa Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
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
nLa The system required 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
revised 9/2198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 138 RICHARDSONS RD.CENTERVILLE
Owner: MARY MCDONOUGH
Date of Inspection:7/26/99
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.
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 ThE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well,
_ The system has a septic tank and soil absorption system and the SAS 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,Method used to determine distance nta- (approximation not valid).
3) OTHER
llLd
revised 9/2/98 Page 3 of 11
I -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 138 RICHARDSONS RD.CENTERVILLE
Owner: MARY MCDONOUGH
Date of Inspection:7/26/99
D. SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303.The basis for this determination is
identified below.The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
X Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool.
X Static liquid level in the distribution box above outlet Invert due to an overloaded or clogged SAS or cesspool.
X Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow,
X Required pumping more than 4 times in the last year NOT due to clogged,or obstructed pipe(s).
j Number of times pumped n1a.
X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
X Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool or privy is within a Zone I of a public well.
X Any portion of a cesspool or privy is within 50 feet of a private water supply well,
X Any portion of a cesspool or privy is less-than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality
analysis.If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic ompounds,
ammonia nitrogen and nitrate nitrogen.
X The liquid level in the SAS is over the invert pipe,is In Hydraulic Failure.
E. LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"to each of the following:
The following criteria apply to large systems in addition to the criteria above:
_ The 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 health and
safety and the environment because one or more of the following conditions exist:
Yes No
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area-IWPA)or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.30412).Please consult the local regional office of the
Department for further information.
revised 9/2198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 138 RICHARDSONS RD.CENTERVILLE
Owner: MARY MCDONOUGH
Date of Inspection:7/26/99
Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following:
Yes No
X Pumping information was provided by the owner,occupant,or Board of Health.
X None 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.
X As built plans have been obtained and examined.Note if they are not available with N/A,
X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non-sanitary or industrial waste flow.
X The site was inspected for signs of breakout,
X All system components,excluding the Soil Absorption System,have been located on the site.
X The 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:
X Existing information,For example,Plan at B4O,H,
X Determined in the field(if any of the failure criteria related to Part C is at issue,approximation of distance is unacceptable)
[1 5.302(3)(b)]
X The facility owner(and occupants,if different from owner)were provided with information on the proper maintenance of
Subsurface Disposal Systems.
revised 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 138 RICHARDSONS RD.CENTERVILLE
Owner: MARY MCDONOUGH
Date of Inspection:7/26/99
FLOW CONDITIONS
RESIDENTIAL
Design flow:_M g.p.d./bedroom
Number of bedrooms(design): 2 Number of bedrooms(actual):2
Total DESIGN flow: 2211
Number of current residents:Il
Garbage grinder(yes or no):MQ
Laundry(separate system)(yes or no): NQ If yes,separate inspection required
Laundry system inspected(yes or no):M
Seasonal use(yes or no):M
Water meter readings,if available(last two year's usage(gpd): n1a
Sump Pump(yes or no): NQ
Last date of occupancy: 6/1/99
COMMERCIAL/INDUSTRIAL
Type of establishment: n&
Design flow: Wit gpd(Based on 15.203)
Basis of design flow: Wit
Grease trap present:(yes or no):�lQ
Industrial Waste Holding Tank present:(yes or no): flLQ
Non-sanitary waste discharged to the Title 5 system:(yes or no):No
Water meter readings.if available:n/a
Last date of occupancy: Wit
OTHER: (Describe)
Wit
Last date of occupancy: Wa
GENERAL INFORMATION
PUMPING RECORDS and source of information:
n[a
System pumped as part of inspection:(yes or no):�LQ
If yes,volume pumped nla. gallons
Reason for pumping: n1a
TYPE OF SYSTEM
X Septic tankidistribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yes or no)(if yes.attach previous inspection records,if any)
I/A Technology etc.Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other: nla
APPROXIMATE AGE of all components,date installed(if known)and source of information:
1973 FOR ORIGINAL SYSTEM WITH A REPAIR IN 1997
Sewage odors detected when arriving at the site:(yes or no) flLQ
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 138 RICHARDSONS RD.CENTERVILLE
Owner: MARY MCDONOUGH
Date of Inspection:7/26/99
BUILDING SEWER:
(Locate on site plan)
Depth below grade: ZLE
Material of construction:_ cast iron X 40 PVC _ other(explain)
Distance from private water supply well or suction line: TOWN
Diameter: nLa
Comments: (condition of joints,venting,evidence of leakage,etc.)
D&
SEPTIC TANK: X
(locate on site plan)
Depth below grade: X
Material of construction:X concrete_ metal_ Fiberglass _ Polyethylene _ other(explain)
nLa
It tank is metal,list age Is age confirmed by Certificate of Compliance(Yes/No): MQ
Wa
Dimensions: L 8'6"H 5'7"W 4'10"
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle: 2C
Scum thickness: 6"
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: 12
How dimensions were determined: MEASURED
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
etc.)
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND_RECOMMEND PUMPING NOW AND EVERY ONE TO TWO YEARS.
GREASE TRAP:
(locate on site plan)
Depth below grade:
Material of construction:_concrete_ metal_ Fiberglass _ Polyethylene_other(explain)
nLa
Dimensions: n&
Scum thickness: n&
Distance from top of scum to top of outlet tee or baffle.:-n&
Distance from bottom of scum to bottom of outlet tee or baffle Wit
Date of last pumping: n&
Comments:
recommendation forpumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,
. .( P q 9�Y�
etc.)
WA
revised 9/2/98 Page 7 of 11
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
I
SYSTEM INFORMATION(continued)
Property Address: 138 RICHARDSONS RD.CENTERVILLE
Owner: MARY MCDONOUGH
Date of Inspection:7/26/99
TIGHT OR HOLDING TANK: NQ (Tank must be pumped prior to,or at time of,inspection)
(locate on site plan)
Depth below grade: nLa
Material of construction:_ concrete_ metal_ Fiberglass _Polyethylene_ other(explain)
nLa
Dimensions: nLa
Capacity: nLa gallons
Design flow: nla gallons/day
Alarm present: N_Q
Alarm level:jita- Alarm in working order:Yes_No_ MQ
Date of previous pumping: nLa
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.)
n/a
DISTRIBUTION BOX: _
(locate on site plan)
Depth of liquid level above outlet invert:n&
Comments:
(note if level and distribution is equal,evidence of solids carryover,evidence of leakage into or out of box,etc.)
PUMP CHAMBER: MQ
(locate on site plan)
Pumps in working order:(Yes or No): MQ
Alarms in working order(Yes or No): MQ
Comments:
(note condition of pump chamber,condition of pumps and appurtenances.etc.)
nLa
revised 9/2/98 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 138 RICHARDSONS RD.CENTERVILLE
Owner: MARY MCDONOUGH
Date of Inspection:7/26/99
SOIL ABSORPTION SYSTEM(SAS): X
(locate on site plan,if possible;excavation not required,location may be approximated by non-intrusive methods)
If not located,explain:
nLa
Type:
leaching pits,number: 1000 GALLON LEACH PIT
leaching chambers,number: 2-INFULTRATORS
leaching galleries,number: _nLa
leaching trenches,number,length: nIA
leaching fields,number,dimensions: nfa
overflow cesspool,number: nla
Alternative.system: nLa
Name of Technology: life
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.)
THE SAS IS FUNCTIONING PROPERLY.
CESSPOOLS: _
(locate on site plan)
Number and configuration: nla
Depth-top of liquid to inlet invert: nLa
Depth of solids layer: nfa
Depth of scum layer. nfa
Dimensions of cesspool: n&
Materials of construction: WA
Indication of groundwater: n& inflow(cesspool must be pumped as part of inspection)nfa
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
nLa
PRIVY: _
(locate on site plan)
Materials of construction:n& Dimensions:n&
Depth of solids: n&
Comments:
(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
n&
revised 9/2/98 Page 9 of I I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 139 RICHARDSONS RD.CENTERVILLE
Owner: MARY MCDONOUGH
Date of Inspection:7/26/99
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
n/a
AL
l �b
t�
is
1�6
�i►�t r,�rs a
revised 9/2/98 Page 10 of 11
r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 138 RICHARDSONS RD.CENTERVILLE
Owner: MARY MCDONOUGH
Date of Inspection:7/26199
NRCS Report name: n/A
Soil Type: nLa
Typical depth to groundwater: nLa
USGS Date website visited: nLa
Observation Wells checked: NQ
Groundwater depth:Shallow _ Moderate _ Deep _
SITE EXAM _ Slope
_ Surface water
_ Check Cellar
Shallow wells
Estimated Depth to Groundwater 12 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_ Obtained from Design Plans on record
Observed Site(Abutting property,observation hole,basement sump etc.)
_ Determined from local conditions
_ Checked with local Board of health
_ Checked FEMA Maps
_ Checked pumping records
_ Checked local excavators,installers
0
X Used USGS Data
Describe how you established the High Groundwater Elevation.(Must be completed)
USGS MAPS AND CHARTS
revised 9/2/98 Page 11 of 11
- TOWN OF BARNP33LE
-.3
LOCATION I Is (�� .I�Y�G+�G1 i SEWAGE # C�
VP LAGE ASSESSOR'S MAP& LOTvA
INSTALLER'S NAME&PH NO.
SEPTIC TANK CAPACITY ZQQ
LEACHING FACII.TTY: (type) (size)
NO.OF BEDROOMS
BUILDER OR OWNER S aM lcxx,
PERMTTDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
` Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by 1�
w
E3
t7P
n op n �a
1 '
� s
TOWN OFnBARNSTABLE
LOCATION iS3 �..� fflrLr SLOE# Z';kS k
VILLAGE ✓a`AVNt`5 ASSESSOR'S MAP&PARCEL e
IN&T*bb4;R'S NAME&PHONE NO "�Y
SEPTIC TANK CAPACITY Loo0
LEACHING FACILITY:(type) hcwhb44'3 (size) ..,, 5`GCU a��
NO. OF BEDROOMS
OWNER 'a y
PERMIT DATE: �E DATE n• P �" "�; 0./
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 leac ' f""a//ciility) Feet
FURNISHED BY {Y`V
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-
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Water ♦,,,♦,♦r•r♦,♦,tftr♦,tr♦f�,�,•,•ft,•,♦,t,•,•ftf f�,�ftrt, ♦,•r
Service ,r,f•f♦';'♦','•'•',` ♦'t':'.`.'.`.`t'•'
21 2
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TOWN OF BARNSTABLE
LOCATION '21 C (5 d 4:A G) R- SEWAGE #
VILLAGE t, ASSESSOR'S MAP & LOT ®—
INSTALLER'S dANE&PHONE NO. 70 7 7 L'
SEPTIC TANK CAPACITY 16329
LEACHING FACILITY: (size)
NO.OF BEDROOMS—,
BUILDER OR OWNER el TK L r4-
PERMIT DATE: 'd l O-2 2 COMPLIANCE DATE: !2- Ql
Separation Distance Between the:
Maximum Adjusted Groundwater Table t/* 'ty)
om of Leaching Facility Feet
Private Water Supply Well and Leachin (If any wells exist
on site or within 200 feet of leaching Feet
Edge of Wetland and Leaching Facilityetlands exist
within 300 feet of leaching facility) Feet
Furnished by
.l '
f `r � '
o _�(M
. v s -
$50
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Application for Me;pogal 6pelem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) O Complete System O Individual Components
Location Address or Lot No. O er's N and Tel.No.
153 Connemara Circle , ;Hyannis , MA ' �
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Wm. E. Robinson Septic Service
PO Box 1089, Centerville , MA
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil Sand
Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system.
D-box and 2 chambers .
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 thi Bo d of Hea h. n (�
Signe ® Date %L10r` /
Application Approved by 0 Date
Application Disapproved for the following reasons
-61
A 0!!:)
Permit No. Date Issued
} 1 p 0
No. D _ Fee 5
1. THE COMMONWEALTH.OF MASSACHUSETTS _ Entered in computer:
—;
PUBLIC HEALTH DIVISION -TOWN.OF BARNSTABLES MASSA HVSETTS Yes
- Z lication for Migpogaf *pgtem �tCon.5truction Permit
Application for a:Permit to-Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components-
• Location Address or Lot No. O ner's and Tel.No.
153 Connemara Circle, Hyannis, MA dam L `
Assessor's Map/Parcel
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. i
Wm. E. Robinson Septic Service
PO Box 1089, Centerville, MA
V T�ype of Building:
Y .. Dwelling No.of Bedrooms 3 Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers,:( ) Cafeteria( )
Other Fixtures.
Design Flow gallons per day. Calculated daily flow gallons. '
' - Plan Date Number of sheets Revision Date
Title
' Size of Septic Tank Type of S.A.S. ;
' L Description of Soil Sand
r
Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system.
D-box and 2 chambers.
Date last inspected:
4:: j
' . Agreement:
The undersigned agrees to ensure.,the construction and maintenance of the afore described on-site sewage disposal system _
in,accocdance 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 IN B d of Health.
'! Signe r C Date
Application Approved by o Date '
Application Disapproved.for the following reasons6L
t
Permit No. - Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
R itker BARNSTABLE, MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired (X )Upgraded( )
Abandoned( j by• bjm• F. Robinson Septic Service
at 1.53 Connemara Circle, Hyannis has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No V,5 dated
Installer Wm. E . Robinson Sr. Designer
The issuance of this pe s•all no be construed as a guarantee that the s ill function as� Sig
�,j Date Inspector I
--------------
No. Fee $52
THE COMMONWEALTH OF MASSACHUSETTS -
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
R itker
Zigpog;al *pgtem' Construction Permit
Permission is hereby granted to Construct( )Repair(X )Upgrade( , )Abandon( )
System located at 53 Connemara C irele, Hyannis
r
and as described in the above Application for Disposal System Construction Permit. The applicant reco nizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
(O
Provided: Constructio must b1corUjIleted within three years of the date of t i p it.
Date: Approved by p r
t
/ TOWN OF BARNSTABLE G� F
LOCATION > C (X A,/',Wd?A SEWAGE #
VILLAGE ^ ems- 5 ASSESSOR'S MAP & LOT D-
INSTALLER'S IAME&PHONE NO. Ku�r a,r c- C
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) (size) "ei s"
NO. OF BEDROOMS 3
BUILDER OR OWNER RI x C►2
PERMIT DATE: O D—T `j COMPLIANCE DATE:
SeparAtion Distance Between the:
Maximum Adjusted Groundwater Table to the B tom of Leaching Facility Feet
Private Water Supply Well and Leaching Fac' 'ty (If any wells exist
I on site or within 200 feet of leaching fac' 'ty) Feet
Edge of Wetland and Leaching Facility ( any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
I t
f
116/99 .
NOTICE: This Form Is To Be Used For the Repair"Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
I .William E . Robinson,s rllereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at 153 MnnnPmara C irele, Hyannis, MA—' meets all of the
following criteria:
o O�failed system is connected to a residential dwelling only. There are no commercial or business
ses sociated with the dwelling.
c e soil is classified as CLASS I and the percolation rate is less than or equal io 5 minutes per inch.
'ere are no wetlands within 100 feet of the proposed septic system _
There are no private wells within 150 feet of the proposed septic system
There is no increase in flow and/or change in use proposed
VThere are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14) feet above the maximum adjusted
groundwater table-elevation,
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information) l,t Z
B) G.W. Elevation +the MAX. High G.W. Adjustment
DIFFERENCE BETWEEN A and B
SIGNED : DATE: d " /
[Sketch proposed plan of system on back].
q:health folder:cent
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THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............ .Gu. ..........OF........
�.�. /�!,fT! G/�.... ........................
�� ►�3 slirtttiun -fur Disposal Works Tottstrurtiun Vrr}nit
Application is hereby made�for a Permit to Construct 0( ) or Repair ( ) an Individual Sewage Disposal
System at: f 1�3 cd-0 1- YhC� 4 C"/.
4L rti zo. � Gv 4 � /(Y�k-wis
r' - -------------------------------------- ....... -
Locatkn-Address or Lot No.
Owner Address
aU a h.o 4...-•-•-----------•----- --_----------------------
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
a, Other Type of Building ____________________________ No. of persons_-___-_.._____-_-_.____.__ Showers ( ) — Cafeteria ( )
t�
d Other fixtures .....................................................................................................................................................
W Design Flow............ ......................gallons per person per day. Total daily flow............................................gallons.
P4 Septic Tank—Liquid capacity__/hLvgallons Length................ Width................ Diameter._.__...i....... Depth................
Disposal Trench—No. ...........:..v;. !idtii----_______-______-- Total Length.................... Total leaching area........... sq. ft.
Seepage Pit No._../D.0d___^l§iameter....................... Depth below inlet.................... Total leaching area....._.._...___..�sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
� Percolation Test Results Performed by.......................................................................... Date........................................
a Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f4 Test Pit Nor. 2................minutes per inch Depth of Test Pit.................... Depth to ground water......................
P4 ...........................................•---•-•--•--•-•--•--•--..........--•--
O Description of Soil.......................................... ---. . - G j1` ��GG........• Y^_. .--
.... ................................................ ......•-------------------------•---------------------------------------....---....---------.........-••••---------------•-----
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 \I of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee ssued by the board of health.
I�
Signed-- . ---• = ------V_>........«----------
--------------------------------
Date
Application Approved By--,-.Ite
... --------------------------------------------------------------------------•---
- ate
Date
Application Disapproved for following reasons:................................................................................................................
.......-•.......................................................•---.......------•----------•-------•--•..-----._._.............--•-••--•-••---•--......-•-----•---.._..._....
Date
Permit No.....15-VAI----------------•--------------------. Issued----� ��
ate
•,t. ��.�..��. ----
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F&E............................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
�`0. .�"..--....OF......../'. /li sT! ,��
Applirtttion -for Uiopooat 10orkii Tattotrurtion Permit
Application is hereby made for a Permit to Construct (< ) or Repair ( ) an Individual Sewage Disposal
System at:
..._....•-•--L- -•j-•--•----�_J ovation --- r.e •----•-••.......................... ------
Location-Address or -Lot No.
i /
Owner Address
Installer Address
UType of Building Size Lot----------------------------Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
pa, Other—Type of Building ............................ No. of persons---______________________-__ Showers ( ) — Cafeteria ( )
Q' Other fixtures ......................................................
W Design Flow____________-___O______________________gallons per person per day. Total daily flow.............................................gallons.
WSeptic Tank—Liquid capacity._&ZI)gallons Length---------------- Width................ Diameter___-__-_--____ Depth................
x Disposal Trench—No_ .......___ ___y,,:_ Nzid�h.................... Total Length.................... Total leaching area_-__-_-_____-_--____sq. ft.
3 Seepage Pit No.__/(/1��._. Diameter___//________________ Depth below inlet.................... Total leaching area..... ft.
Z Other Distribution box ( ) Dosing tank ( )
1-4 Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
f1 Test Pit No. 2----------------minutes per inch Depth of Test Pit.................... Depth to ground water........................
C+ -••------------------- -----------------•--....-•--••--•-_--•- •-----
O �l:�f> - GAL- �Y- j�'l.�cy
Description of Soil------------------••-----....__...._.__.._. l .:-:------....._.................
rJ ----------------------------------- -
W _..... ---•-•••• ...---••---------•••----------•----••--•••-••-._.._..._..•------•••----•••••----•-••---••--.-...--••--•---••••-•-------------------
U Nature of Repairs or Alterations—Answer when applicable_______________________________________________________________________________________________
--••--------••-•-•------------------•---------------•-------------------------__________-•---•--_-______---_________-•-----_____-----•--------------•------••------------------------------------------
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has b�_'1__S_ _
isued by the board of health.
Signed-- .^"'�9"._-------K•----• ••--_...---•• --- .....................
ApplicationApproved BY = ---�- ------------------------------------------------•-------------•---------------- .....................Date----------•-•-
/ _._..------•------•------•••-•--•--•..................Date......._Application Disapproved for tll.e following reasons: ___.__
............................................•-------•---------._._...__...--•-------...----------•--•---------•--•-•---•--•-•-••--•-••-------I-------- --------•----------•----•-•• --•••--------•-
Date
Permit No.-_ .�::4/-°J-------------.......................... Issued..../-�'-- �- f
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
(11rrtifirate of Tompliattrie
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed or Repaired ( )
by---------------........................................d /�/lc 5 -
Installer
at......... r e� f:.T/ La ram:-`..___.__.. ��!/.............- `/T �� !`'� ''
-----------------------------------•--..._..--•---.._..•-••-•-••••---..._------
has been installed in accordance with the provisions of Article XI of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No ...___ _ ____________________ dated...... __-_�_-- ..........................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT TIME
SYSTEM WILL FUNCTION SATISFACTORY.
DATE................................................................................ Inspector....................................................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No------------------------- FEE........................--......--
Dinpoiial Norkii TIonstrurtiott Permit
Permission is hereby granted.__.:"�' T/�:�`'......................................a.............................................................................
to Construct or Repair ( ) an Individual Sewage Disposal, System,
at No----------='----T-=- `3 �/ / T h,it i:.l
i
----_,.----------------------------------------------••-•----------- ------------------------------------------------•---------------------------------------
Street ,�
as shown on the application for Disposal Works Construction Permit No..__..___���'%____ Dated.....__-:: _�" �7
-----•---.....-•-•-•---•.............................................•-----._._..----._..__..._.---_..._
Board of Health
DATE................................................................................
FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS
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.E.RT' l F1* ED SLOT PLAN
L o c.A r i o H: H ,9.y vis
SCALE: -'_f- 2 DATE -Za_sc i973
RE E R E N C E:
f K-EREHY CERTIFY THAT THE BUILD [ Nrf. REG. LAND SURV YOR
S H O W N ON THIS PLAN f S LOCATED O
`M"E, GROUND AS SHOWN HEREON AND
TKIAT' • Ir CONFORM TO THE OF
Z ONAN G BY-- LAWS OF THE TOWN OF
y
i7.e�sT-g�G�'WHE N CONSTRUCTED.
MQNAHAN,
i�-ARNSTABLE SURVEY CONSULTANTS, INC.
WEST YARMOUTH, MASS . "1•Y