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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
13 Denver Street
Property Address
Owner Stephen Washkevich `t
information is
required for every Owner's Name r
to
page. Hyannis MA 02601 October 8, 2019
City(rown State Zip Code Date of Inspection . .
r.
Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see
completeness checklist at the end of the form.
A. Inspector Information 614 1' la3aL--
1. Inspector:
Michael DeCosta,Jr.
Name of Inspector
Wind River Environmental
Company Name
46 Lizotte Drive Suite 1000
Company Address
Marlborough MA 01752
City/Town State Zip Code
508-400-8083 S1 13230
Telephone Number License Number
B. Certification
I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5(310 CMR
15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information
reported below is true,accurate and complete as of the time of my inspection;and the inspectiion was performed
based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.
After conducting this inspection I have determined that the system:
Q Passes
❑ Conditionally Passes
❑ Needs Further Evaluation by the Local Approving Authority
❑ Fails
October 8,2019
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection. If the system 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.
Please note:This report only describes conditions at the time of inspection and under the conditions of
use at that time.This inspection does not address how the system will perform in the future under the
same or different conditions of use.
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
o
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8, 2019
City/Town State Zip Code Date of Inspection
C. Inspection summary
Inspection Summary: Complete 1,2, 3,or 5 and all of 4 and 6.
1)System Passes:
Q 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:
2)System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be replaced
or repaired.The system, upon completion of the replacement or repair, as approved by the Board of
Health,will pass
Check the box for"yes","no"or"not determined"(Y, N, ND)for the following statements. If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound,
exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved,by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below)
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 19
� Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8,2019
City/Town State Zip Code Date of Inspection
C. Inspection summary (cont.)
2)System Conditionally Passes(cont.):
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
❑ Observation of sewage backup or break out or high static water level in the distribution box due to
broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass
inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system
will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
3)Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect public health,safety or the environment.
a.System will pass unless Board of Health determines in.accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
t5ins.doc 9 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 9 Page 3 of 19
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8,2019
City/Town State Zip Code Date of Inspection
C. Inspection summary (cont.)
❑ 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
b.System will fail unless the Board of Health(and Public Water Supplier, if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface
water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private
water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5
ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.
c. Other:
4)System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ Q Backup of sewage into facility or system component due to overloaded or clogged SAS
or cesspool
❑ Q Discharge or ponding of effluent to the surface of the ground or surface waters due to
an overloaded or clogged SAS or cesspool
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
13 Denver Street
Property Address
Owner Stephen Washkevich
information is Owner's Name
required for every
page. Hyannis MA 02601 October 8, 2019
City/Town State Zip Code Date of Inspection
C. Inspection summary (cont.)
4) System Failure Criteria Applicable to All Systems: (cont.)
Yes No
❑ 0 Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool
❑ Liquid depth in cesspool is less than 6"below invert or available volume is less than Y2
day flow
❑ 2 Required pumping more than 4 times in the last year NOT due to clogged or obstructed
pipe(s). Number of times pumped:_
❑ z Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ z Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary
to a surface water supply.
❑ Q Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ z Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ z 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.]
❑ 0 The system is a cesspool serving a facility with a design flow of 2000gpd-10,000gpd.
❑ 171 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.
5) 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 CA.
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
t5ins.doc rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System 0 Page 5 of 19
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
o
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8,2019
City/Town State Zip Code Date of Inspection
C. Inspection summary (cont.)
If you have answered"yes"to any question in Section C.5 the system is considered a significant threat,or
answered"yes"in Section CA above the large system has failed.The owner or operator of any large system
considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in
accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the
Department.
6. You must indicate"yes"or"no"for each of the following for all inspections:
Yes No
Q ❑ Pumping information was provided by the owner,occupant, or Board of Health
❑ Q Were any of the system components pumped out in the previous two weeks?
Q ❑ 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?
Q ❑ Were as built plans of the system obtained and examined?(If they were not available
note as N/A)
Q ❑ Was the facility or dwelling inspected for signs of sewage back up?
Q ❑ Was the site inspected for signs of break out?
Q ❑ Were all system components, excluding the SAS, located on site?
Q ❑ 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?
Q ❑ Was the facility owner(and occupants if different from owner)provided with information
on the proper maintenance of subsurface sewage disposal systems?The size and
location of the Soil Absorption System (SAS)on the site has been determined
based on:
Q ❑ Existing information. For example,a plan at the Board of Health.
❑ Q 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)]
t5ins.doc rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 19
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8,2019
Citylrown State Zip Code Date of Inspection
D. System Information
1. Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 220 GPD
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes 0 No
Does residence have a water treatment unit? ❑ Yes Q No
If yes, discharges to:
Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes Q No
information in this report.)
Laundry system inspected? ❑ Yes Q No
Seasonaluse? Z Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Detail: .
Unavailable
Sump pump? ❑ Yes Q No
Last date of occupancy: Current
Date
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
o
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for eve Owner's Name
q every
page. Hyannis MA 02601 October 8, 2019
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
2. Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CM 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft.,etc.):
Grease trap present? ❑ Yes ❑ No
Water treatment unit present? ❑ Yes ❑ No
If yes, discharges to
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
Last date of occupancy/use:
Date
Other(describe below):
General Information
3. Pumping Records:
Source of information: Wind River Environmental—See attached.
Was system pumped as part of the inspection? Yes ❑ No
If yes,volume pumped: 1000
gallons
How was quantity pumped determined? Measured by the pump truck.
Reason for pumping: Check structural integrity of the tank.
t5ins.doc rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
13 Denver Street
Property Address
Owner information is Stephen Washkevich
required for every Owner's Name
page. Hyannis MA 02601 October 8,2019
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
4. Type of System:
Q Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance
contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by
system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
Approximate age of all components, date installed (if known)and source of information:
Approximately 35 years
Were sewage odors detected when arriving at the site? ❑ Yes 0 No
5. Building Sewer(locate on site plan):
Depth below grade: 1
feet
Material of construction:
❑ cast iron Q 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: N/A
feet
Comments(on condition of joints,venting,evidence of leakage, etc.):
All the joints are sealed and there are no leaks.
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 19
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8, 2019
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
6. Septic Tank(locate on site plan):
Depth below grade: 6"
feet
Material of construction:
Q concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 8'x 5'x 4'
Sludge depth: 4"
Distance from top of sludge to bottom of outlet tee or baffle 38"
Scum thickness 4"
Distance from top of scum to top of outlet tee or baffle 6"
Distance from bottom of scum to bottom of outlet tee or baffle 15"
How were dimensions determined? Tape Measure
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
All the covers are 6"below grade.The tees are good.There is no filter.installed on the outlet.The liquid level is
normal with moderate solids and sludge.The tank appears to be structurally sound and not leaking. Recommend
installing a filter on the outlet and pumping the tank annually.
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
o
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8,2019
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
7. Grease Trap(locate on site plan):
Depth below,grade:
feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping:
Date
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
t5ins.doc rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 19
Commonwealth of Massachusetts
- Title 5 Official Inspection Form,
Subsurface Sewage Disposal.System Form -Not for Voluntary Assessments
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8,2019
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
8. Tight or Holding Tank(cont.)
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
9. Distribution Box(if present must be opened)(locate on site plan):
Depth of liquid level above outlet invert 0
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of
leakage into or out of box, etc.):
The distribution box is 18"below grade and 16"x 20".The box has one outlet to the leach pit.The liquid level is
normal with minimal carryover into the box.The box is in good structural condition, is watertight and is not
leaking.
l5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 19
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8, 2019
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
10. Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
11. Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
Type:
0 leaching pits number: 1
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
t5ins.doc 9 rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 19
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8,2019
CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
11. Soil Absorption System (SAS)(Cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
The leach pit is 2'below grade with over 4'of available space and no evidence of high stains.There is no
evidence of hydraulic failure and the vegetation is normal.
12. 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.):
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8,2019
Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
13. 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.):
t51ns.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8,2019
CityfTown State Zip Code Date of Inspection
D. System Information (cont.)
14. Sketch Of Sewage Disposal System:
Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of
the boxes below:
Q hand-sketch in the area below
❑ drawing attached separately
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t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
o
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8, 2019
City/Town State Zip Code Date of Inspection
D. System Information (cont.)
15. Site Exam:
Q Check Slope
Q Surface water
Q Check cellar
Q Shallow wells
Estimated depth to high ground water: 91+
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
Q Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
There are approximately 9'to the bottom of the stone in the pit. Pumped the pit and observed no groundwater
infiltration.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 17 of 19
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8,2019
City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
Complete all applicable sections of this form inclusive of:
Q A. Inspection information:Complete all fields in this section.
Q B. Certification: Signed&Dated and 1,2,3, or 4 checked
Q C. Inspection Summary:
1,2, 3,or 5 completed as appropriate
4(Failure Criteria)and 6(Checklist)completed
Q D. System Information:
For 8:Tight/Holding Tank-Pumping contract attached
For 15: Sketch of Sewage Disposal System drawn on pg. 16 or attached
For 16: Explanation of estimated depth to high groundwater included
t5ins.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 18 of 19
' `<L Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
" 13 Denver Street
Property Address
Owner Stephen Washkevich
information is
required for every Owner's Name
page. Hyannis MA 02601 October 8,2019
City/Town State Zip Code Date of Inspection
Pumping Record
Work Order._'0217074553 Cust S 2 190 658 Customer Since:2019 Tax:6.250 0 9
Job Comments Tech Comments
10/81201.9 Signed conoant form in office vith TA, coat to be 1 pulled plauo they are.in the ace t JL.
on.sita vitb water reoorda. No closYng data. ++r0'1�7 Rotor+• 10/1 11L*XaD,
Sap
tle Glrstwo, coot advised rcpart sent 3 Vks attar data 20193911969. eoc,D'M20dad No P.ecmmaridation.
of incpactios.
System Owner System Location
atapts7a ihsblo:nvlctt Primary Home .
13.Dewar Strait 13 Damrer 8trapt
Hya®1q, '02601 Hyannis,l6A 02601.
isoei 769-0716' 'Raabkevich : [506) 769-0716
SeroiceDate-, TUB 10/08/2019 07,30 12r F cam to confirm:
_ Frequency:
Service Type. Standard PreviousService:-0912612019
Approx. eats: o CCLS: Location Details:
Depth.Below Grade: custom Clean:
Cust Rome: NO Filter..
Township- InspectionM:
County: "Barn�tat;lo `_ - Build up: —.'. 7 7
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Desa iption- Qt� lhdt Prke EKt_Noe
inspection title s {not incluGixxj punpingi,� `qri 1.00 '365.0000',9, 365..00 "-`: ij
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loop
ritlo s BOB Pesos , , 1 Do y r xs.ODdo�9 ;25.0a
Pumping 1000 Ir' i +' 1 00 3 2s7.6as4. 9 257:69
Dunpin 1001 - 1500 -..' 1 tt 0.00 .9;37Q.7636�9'� 0.00
6Drisabuebtal C nl1 anne RQs1A ntlal' '^ '1:00',s� 3.0000 9" "x' 3..00
Bual l Energy}}EacoTory 1.00 59 L556 9 59.16
i-Aucu:9 709.es Wesu�dt these 3 keys steps'tokeepyoyrrys�Nattily:
rn :9 0.00 RepAur;owc�H.Sbactt�riaaddltke
16LO $ 709.a5 •Ube a fills .
vo5at Site: Disposal Vo9lane: Payment Detail:
Waste Cade: 0.000D Vita 1 X)000=8609 06/2023
S3AesRep: HE_R&palry raatalls CSR, ¢atriaa Alford nue on.Receipt
Truck: Technician:MLcmaol DGMMta Jr. on Site:0e:50 AK P 0 ktBri)ter:
Techkaaes:.
5yateo 4perating.Fine. NOEMa.vatQT level. lsght top dal dc.. Light bottom f
sludge. Both barrlm'are intact. Main line clear. Ho filter is-"present on the `cif
tank; aaTrent tank can ba outfitted with a filter. Dover(a) secured. Title S
inmpectloa..paso, full report.will ba edailad to container, tech to pump later
today 1000.gals, all set-thank you: Baen7maadad No RsctaaebdatSdh. x �.
customer Signature _
W I r E
ENVIRONMENTAL
t5ins.doc rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 19 of 19
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL. PROTECTION
MAP
PARCEL
TITLE 5 LCT
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
RECEIVED
Property Address: 13 Denver Street
Hyannis, MA 02601 J A N 06 2G 03
Owner's Name: Anita Hayden
Owner's Address: Same
TOWN OF BAFii4STABLE
HEALTH DEPT.
Date of Inspection: November 20, 2002
Name of Inspector: (Please Print) James M. Ford L 0 (Z�Z
Company Name: James M. Ford
Mailing Address: P.O. Box 49 Map:291
Osterville,MA 02655-0049 Parcel. 310
Telephone Number: (508) 862-9400 Lot: 93
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported
below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my
training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP
approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system:
✓ Passes
Cond' ' nally Passes
Need F rther Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: December 11, 2002
The system inspector shallIsubit 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.
Notes and Comments
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
• Page 2 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 13 Denver Street
Hyannis, MA
Owner: Anita Hayden
Date of Inspection: November 20, 2002
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
✓ I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined", please
explain.
The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s)are replaced
obstruction is removed
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:
2
r
Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 13 Denver Street
Hyannis MA
Owner: Anita Hayden
Date of Inspection: November 20, 2002
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require finther evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the.environment:
_ Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ 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 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,provided that no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
• Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 13 Denver Street
Hyannis, MA
Owner: Anita Hayden
Date of Inspection: November 20, 2002
D. System Failure Criteria applicable to all systems:
You must indicate either"yes"or"no"to each of the following for all inspections:
Yes No
_ ✓ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
✓ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
✓ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
✓ Liquid depth in cesspool is less than 6"below invert or available volume is less than 'I/ day flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
_ ✓ Any portion of the SAS,cesspool or privy is below high ground water elevation.
✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 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 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,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this forma
No (Yes/No)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 System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
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)
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.
4
• Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 13 Denver Street
Hyannis, MA
Owner: Anita Hayden
Date of Inspection: November 20, 2002
Check if the following have been done: You must indicate`yes"or"no"as to each of the following:
Yes No
✓ _ Pumping information was provided by the owner,occupant,or Board of Health
✓ Were any of the system components pumped out in the previous two weeks?
✓ _ Has the system received normal flows in the previous two week period?
✓ Have large volumes of water been introduced to the system recently or as part of this inspection?
✓ _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
✓ Was the facility or dwelling inspected for signs of sewage back up?
✓ _ Was the site inspected for signs of break out?
✓ _ Were all system components,excluding the SAS, located on site?
✓ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum ?
✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ _ 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(3)(b)].
I
5
Page 6 of I I
T OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 13 Denver Street
Hyannis, MA
Owner: Anita Hayden
Date of Inspection: November 20. 2002
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 2 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
Number of current residents: 1
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Currently occupied
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information: Pumped in June 2002-per owner
Was system pumped as part of the inspection(yes or no): 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:
Jun 19178-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 13 Denver Street
Hyannis, MA
Owner: Anita Hayden
Date of Inspection: November 20, 2002
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: Approx. 16"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: _ 1000 Qal.
Sludge depth: 1"
Distance from top of sludge to bottom of outlet tee or baffle: 31"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 10"
Distance from bottom of scum to bottom of outlet tee or baffle: 12"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
Tees were present The liquid level was even with the outlet invert. There were no signs of leakage.
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 13 Denver Street
Hyannis, MA
Owner: Anita Hayden
Date of Inspection: November 20, 2002
TIGHT or HOLDING TANK: None (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _fiberglass _polyethylene _other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present(yes or no):
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches,etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
The D box was broken down structurally, A new D-box was installed(Permit#2002-559).
PUMP CHAMBER: None (locate on site plan)
Pumps in working order(yes or no):
Alarms in working order(yes or no)
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
8
F
Page 9 of 11
y OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 13 Denver Street
Hyannis, MA
Owner: Anita Hayden
Date of Inspection: November 20, 2002
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
✓ leaching pits,number: 6'x 6' -1000 gal.
leaching chambers,number:
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.):
The pit had approximately 4'ofwater on the bottom The scum line was at the same ievel. There were no signs offailure. The
bottom to grade was approximately 9' The cover was approximately 2'below grade.
CESSPOOLS: None (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 or no):
Comments (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
PRIVY: None (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.):
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 13 Denver Street
Hyannis, MA
Owner: Anita Hayden
Date of Inspection: November 20, 2002
Map:291
Parcel:310
Lot.93
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.
Pr Onl Q
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3 30 ay
10
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 13 Denver Street
Hyannis AM
Owner: Anita Hayden
Date of Inspection: November 20, 2002
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 20' +/- feet
Please indicate (check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record- If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: Topographic and water contours maps
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
The bottom of the leach pit to grade was approximately 9' Using the Barnstable topographic map and the Cape Cod
Commission water contours map the maps were showing approximately 20'+/-to ground water at this site.
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
Fee
�V
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Application for �Digogal *pttem Cow6truction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. /J OE A)109 n S 4 (��ner ame,Address d Tel.No.
Assessor's Map/Parcel aj/ 3 y/a Ai lll is f 3 v�iv A �u� J APW S
D Tl I"'y
Installer's ame,Address and 761.No. �,C'�y�� �jla 8 Sb Designer's Name,Address and Tel.No.
0STEK 101l'
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
Nature of Repairs or Alterations(Answer when applicable) Ar o A<F_ �� o
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 is y thi Board o Heal
Signed Date ///10 0eZ
Application Approved by Date �(— 2-0? -
Application Disapproved for the following reasons
Permit No. `200 2 Date Issued /l 2 Z16
J Fee /
l THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
' Yes
P ! PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS
0 pricattion for Migpogal ,*pgteni(Congtruction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) ❑Complete System El Individual Components
L4
Location Address or Lot No. �3 �,`Av LIS 7 �� wne}TName,Address and Tel.No.
Assessor's Map/Parcel a�/ 3 j 0 f !�y ) /3 DZ N u Address
�f]yAW lu l s
Installer's Name,Address,and el.No. rCoB� �/d Q s`H 6 Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Type of S.A.S.
Description of Soil
ICNature of Repairs or Alterations(Answer when applicable) ��� « /.J SOX
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 issu y thi Board o Heal
RKA Signed Date 114 ,a
Application Approved by Date
Application Disapproved for the following reasons i
Permit No. ZUU 2 —S j 9 Date Issued //12
--------- ----------- ------ --------
THE COMMONWEALTH OF MASSACHUSETTS
,� 1 BARNSTABLE MASSACHUSETTS
D0 I.:°T° Certificate of (Compliance r
THIS IS TO CERTIFY,that the On-site Sew/age Disposal System Constructed( )Repaired(Upgraded( )
'Abandoned( )by �YyC�tJ
at has been constructed in accordance
with the provisions o-,Title 5 and .e for Disposal System Construction Permit No. Z+bO 2`SSg dated IL 22—U 2
Installer Designer
The issu ce of this`perit s mhall not b construed as a guarantee that the system will function as designed.
Date I'}_1-�`to Inspector ✓1 /11 ��
---------------------------------------
No. Fee �d
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
lwigpogar *pMem ongtruction Permit
0
13 Permission is hereby granted to Construct( )Repair( )Upgrade( )A andon
( )
System located at /2 DF_.,V R
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this
Date: 21 Approved by
i
TOWN OF BARNSTABLE LOCATION I IJG/1UC/ SE AGE # �JOa`5s I q
VILLAGE 1AV AAtN1S `' 9
ASSESSOR S MAP & LOTa 3/0
INSTALLER'S NAME&PHONE NO. QeCly^ &o% VS
SEPTIC TANK CAPACITY f UVl) - VK rt4A
e .
LEACHING FACILITY: (type) (size) /QR b
NO.OF BEDROOMS
4 �
BUILDER OR OWNER Al A 1-1 A,,4 A
PERMITDATE:. .11 _X a COMPLiACE 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
PrOA
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/ TOWN OF BARNSTABLE
LJCATiON 13 LeAUei SEWAGE # CkAa` 55
!Ii.AGE IAN AAr11.S ASSESSOR'S MAP & LOT S 10
INSTALLER'S NAME&PHONE NO. �jo�Glon RVIh VS
SEPTIC TANK CAPACITY ^ ) 1-�," y roA �
LEACHING FACILITY: (type) (size) _ion
NO. OF BEDROOMS t
BUILDER OR OWNERPERMIT DATE: a a COMPLIANCE DATE: a �
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
Pro^r ry
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3 3o ay
36 *3
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L,b_ CAT I N 1-3SEWAGE PERMI NO..
—
VI. LA E
7f
INSTA LLER'S NAME & ADDRESS
B U I*L D E R OR OWNER
ga
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DATE PERMIT ISSUED ..
DATE CO-MPL.. IANCE ISSUED �� �
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2 TOWN OF�B-ARNSTABLE
'.:CIf'ATON I J ��VC/ J t SEWAGE #
:LAGE_ 1TI �11S ASSESSOR'S MAP & LOTd191, 31d
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 10W G^)
LEACHING FACILITY: (type) IT G X (size) I OVo 5h
p NO. OF BEDROOMS '
BUILDER OR OWNERS
PERMITDATE: 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 fa ility) �-� Feet
Furnished by CiD^
I -
.. �. 4
a � _
3
g � y
a a as
3 3o ay
79 �
N4......... •....6.. �. Fina............................
_ _
THE COMMONWEALTH OF MASSACHUSETTS
BOARDF HEALTH
i- . ........OF............�.........................................................
Appliration -fur Uiipnaal Works Tomitrurtiott Vamit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
Syst at
r �a,t._•• R 1 �! G:L,1.1_Y.l!_L_�l� L._ ! 4���/. ------No.
•----•--•--------•--
Owner / ♦ Address i'
Installer Address ,y,
d of Building Size Lot_j ---� ...Sq. feet
76
ZType
UDwelling—No. of Bedrooms.-.-__--_ _..._Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
Q Other fixtur� �.--
-------------------- - ----------------------------------------------------------------•-----------
W Design Flow____________________ ________ gallons per person per d&y. Total dai� flow_......_ -�__ gallons.
W Septic Tcuik—Liquid ca pacity allons Length Width..
1 q 1 � g` g ----- __------- lliameter---------------- Depth----------------
Disposalx Trench—N .. Width____- _A.... Total Len th---_____� Total leaching area
---------- g /-----��- gsq. ft.
Seepage Pit No_______ _________ Diameter__________Y...... Depth below inlet__�._�....... Total leaching area-1 ---sq. ft.
z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by._----.�A/ g f...._.._� ._. Date..../0 �'_----- I;?'-.
Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water...---.�-_j-._-..--X/
(_ Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-._../ ..--.
------------ / f . .-- --------------------------•----------
-
Description of Soil------------ � L� vl � .
• - - -------------------------
Description of
W -------------------------------------- --- ------
VNature of Repairs or Alterations—Answer when applicable.-----------------------------------------------------------------------------------------------
--•---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Agreement: J'
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article NI of the State Sanitary Code—The undersigned-further agrees not to place the system in
operation until a Certificate of Compliance has bee issued by the board o€^health
SIned.-- --- LAC --- --------------------------------
Date
Application Approved BY 4 —------------------ --1e� ------
Date
Application Disapproved for the following reasons-----------------------------------------------------------------------------------------------------=-----------
-----•-•-•--•--------•------•-------•-----•----------------------•----------------•---•--•------•-•-•---------•--•-----------------•-------•----•--- . ------------------------...---------------
/ ® Date
Permit No......................................................... Issued------d -•••--
"l. "_ f
Date
�
077�)
! ,f ti., , Finc..................:...........
THE COMMONWEALTH OF MASSACHUSETTS
BOARD 9F HEALTH :
F' t
... ............
Applirtt#iun -fur UWpauttl Works C�uu #r rtinYik Prmtit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual,Sewage Disposal
System at
t .........s_ s ,r k-III/a ,
.... ...
o - or Lot No
f/) 47 Owner 4 Address
�. ______________________________ f . _'_" --__-_---_____________-_---
---'•-' � r��dress -
Installer n,
Q Type of Building Size Lot_� ----Sq. feet
Dwelling—No. of Bedrooms..--_--_� __________________________Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( )
a' Other fixtures r
Design Flow--------- ---- ---- ---—............._ gallons per person per day. Total daily'flow--____ c ...................gallons.
WSeptic Tank—Liquid capacity -gallons Length.._....____ Width_ Diameter_--._. _ _ Depth. _. --_ .. .
x Disposal Trench— o_____________________ Width____.--.t-_-----_-- Total Length-------- ,_. Total leaching area-------------.......sq. ft.
Seepage Pit No......y__.._...__. Diameter---------- -___-_ Depth below inlet_ ._ `-_____._ Total leaching areri_61-1 ---sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
'-' Percolation Test Results Performed by-------
` f" ....
Date----
Test Pit'No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water_--__---_-__.-.
4. Test Pit'No. 2................minutes per inch Depth of Test Pit--------------------- Depth to ground water.....; -----------
-
O Description of Soil_-•-------- t ... - ---•-- - --- - - ------ - --
x '-------- -----------
W
U Nature of Repairs or Alterations—Answer when applicable..-----------------------------=----------------------------------_.---..__..._._.--.---. --
Agreement
The undersigned -agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of Article XI of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board.of healthy'` n
t ned ---- �� �
Date.
•-
Application Approved By------------------{-. - D
- ate
Application,Disapproved for the following reasons-------------_------------- ------------------•----------------------------------------------------------------
--------------------------------------------------------------------------:----- -- ------•-----------------------------------------------------------------------=---- -----------------------------,
Date
Permit No......................................................... Issued... ------ -. lC
_ Date
" THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH, .
� lerr#ifirair of Tompliaur
THIS IS TO CERTIFY, hat the Individual Se e Disposal System constructed (4) or Repaired ( )
bY---•----- -, ........_ ------------t-------------------- ...........................................� �•^. .. ..�s alley
t � Mp
at ----•---1.... ---• I �� �� � -•------••---•---- --------••-•--•---------•----------------- -------•--••---•------••••••--••--•----•-------
has been installed in accordance with the provisions of A i'cl`'6 XI f he State Sanitary Code as described in the
r application for Disposal Works Construction Permit No.___ 7__.____ AA-------- dated...._J____1!�__A---7............
THE ISSUANCE OF THIS CERTIFICATE SHALVNOT BE CONSTRUED AS.A GUARANTEE THAT THE
`:SYSTEM W LL F N TION SATISFACTORY..
6 y
DATE.------
74r...•-•------•--------------------- Inspector----,--� h....
O�#..
` r --••----•--•----
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEAL'TH
Bi-spulittl rkq Cllaufi#rur tollYrrutit
Permission is hereby granted__ " . . ' .. _._-.. • r
to Construct ( )nor Repair ( .) an Individual Sewage Disposal System z
atNo......."� � ,.--•----•--•------------- ----- -- -------------------------------- -------- .................
Street
as shown on the application for Disposal Works Construction 'Pe
} �.,_,, •'7 �� N ..:
Dated---_ ..`_ � ?_ . ______-
__
—0 ----------------------------
Bo
ard of Hea Zjh
DATE. w . '= _---- - ...............................-
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