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Home My WebLink About0130 DOLPHIN LANE - Health 130 Dolphin Lane Hyannis P f A = 268 174 0 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Name information is required for every West Hyannisport MA 02672 05/25/12 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computes, U use only the tab 1. Inspector: V key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections Company Name ° PO Box.896 Company Address East Dennis MA 02641 Citylrown State Zip Code 508-385-7608 SI 3742 Telephone Number license Number B. Certification J 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 iftpecbo was performed based on my training and experience in the proper function and maintenance of.,on sit6=_ sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of'`r' Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority y 05/29/12 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. "*"This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's(dame information is required for every West Hy p annis ort MA 02672 05/25/12 page. City/Town state Zip Code Date of Inspection B. Certification (cont.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Check the box for"yes","no"or"not 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 11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Name information is required for every west Hy p annis ort MA 02672 05/25/12 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are 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): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR i5.303(1)(b)that the system is not functioning in a mannerwhich 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 wi7u•i ii iv Tle 5atkcial IT.Wc`rm Fo1i'SUUSufttr.Sewaye DSposal Sy-stem•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Name information is required for every West Hyannisport MA 02672 0525/12 page. Cityrrown state Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS 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. 3. Other: I D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6°below invert or available volume is less than day flow t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Name information is required for every West Hyannisport MA 02672 05/25/12 page_ City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped: ❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.) ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails.I have determined that one or more of the above failure criteria ebst 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 11 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, t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Name information is West H annis ort MA 02672 05r25112 required for every y p page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate`fifes"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? El ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS,located on site? ® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information.For example, a plan at the Board of Health. ® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)) D. System Information Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x.#of bedrooms): 330 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Name information is required for every West Hyannisport MA 02672 05/25/12 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: 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 Z No Seasonaluse? ❑ Yes ® No Water meter readings,if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 09/11 Date V CommerciaUlndustrial 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: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owners Name information is West Hyannisport MA 02672 05/25/12 required for every City/Town State Zip Code Date of Inspection page. D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank,distribution box,soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system(yes or no)(if yes,attach previous inspection records,if any) ❑ Innovative/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): t5ins•11/10 Title 50rricial Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Name information is required for every West Hyannisport MA 02672 05/25/12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components,date installed(if known)and source of information: 01/30/92 per BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 2.5 Depth below grade: feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting,evidence of leakage,etc.): Septic Tank(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑metal El 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: Sludge depth: t5ins•11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form sr Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Name information is required for every West Hy p annis ort MA 02672 05P25/12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 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 t5lns•1 V10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Name information is required for every West Hy p annis ort MA 02672 05/25/12 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): 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 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 t5ins•11110 Title 5 Ofrxial Inspection Form:Subsurrace Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Name information is required for every West Hyannisport MA 02672 05/25/12 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert even Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): The box was level and tight with no sign of carryover. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): l Soil Absorption System(SAS)(locate on site plan,excavation not required): If SAS not located,explain why: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Name information is required for every West Hyannisport MA 02672 05l25/12 page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,length: ❑ leaching fields number,dimensions: ® overflow cesspool number: 2 ❑ innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,etc.): This system has a 6'x6'precast pit surrounded a foot of stone.The second pit was a drywell block pit.there was no sign of ponding or failure in either. Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration 3 main pit to box to 2 overflows Depth—top of liquid to inlet invert 26" Depth of solids layer 3" Depth of scum layer 1" Dimensions of cesspool 5'x5' Materials of construction drywell block Indication of groundwater inflow ❑ Yes ® No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Name information is required for every West Hy p annis ort MA 02672 05/25/12 page. Cityfrown state Zip Code Date of inspection D. System Information (cont.) Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.): r i , t5ins•11/10 Title 5 Official Inspectlon Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Flame information is required for every West Hyannisport MA 02672 05t25/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building.Check one of the boxes below: 0 hand-sketch in the area below ❑ drawing attached separately a� a� t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Name information is required for every West Hy p annis ort MA 02672 05/25/12 page. Citylrown state Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health-explain: ❑ Checked with local excavators,installers-(attach documentation) ® Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-11/10 Tine 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 130 Dolphin Lane Property Address Denise Morin Owner Owner's Name information is required for every West Hyannisport MA 02672 05/25/12 page. City/Town state Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary:A,B,C,D,or E checked ® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file II t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 1� 93 DATE : 6/®Q3/03 PROPERTY ADDRESS: 130 Do l2h.in Lune ----------------------- __�e.st Kyann.i6/1oat, Na-6.6___ ------------------------ On the above date, I inspected the septic system at the above address, This system consists of the following: 1. 2-6 'X8' giock cez,3/2oo.2-6 2. 1-Dizta.igut.ion Sox, 3. 1- 1000 ga2.2on gaeca.st 2each.ing 12it. Based on my inspection, I certify the following conditions: 4. 7h.iz 1,3 not a t.it.2e live use/2t.ic, .6ystem. 5. 7h.i,3 i.6 a zewage •6y•6tem that haz had a 1000 gai.2on /2aeczat .ieach.ing /2.it added .in aanuaay 1992. 6. The .sewage 6y,3tem .iz in /zao/2ea woak.ing oadea at the /?aezent time. SIGNATUR. ,Name : _ J__ P__Macomber_Jr Company:, oa tt?h pJ_M�r4mt tC 8_ Son, Inc . A00ress : @(2x _6(�------------ J CVe;PgtE -_QJeJ)S Q t Y i LLQ,_^J a__Q.Z_6 3 2-0 0 6 6 �oW NEPt Pnone : 508- 775_ 3338 -------- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY - JOSEPH P. MACOMBER & SON, INC. Tanks Ca$ spoo'$'LeachII'Ids Pumped & Installed Town Sewer Connections P.0 Box 66 Centerville. MA 02632.0066 175.3338 775 6412 COMMONWEALTH OF MASSACHUSETTS = EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION a TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 130 Do.012h.in Lane Uezt Hyannzzpoat,77—azz. Owner's Name:/2o geat Molt-in Owner's Address: Same Date of Inspection: 6/, 3/0 3 Name of Inspector: (please print) aozel2h %. MacomPkea a2. Company Name: 7. P. flacomge2 & Son Inc, . Mailing Address:13ox 66 Centeay.i..2.2e. MaA.s. 02632 Telephone Number: 5 0 8-7 7 5-3 3 3 8 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 trairking 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: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 'd The system inspector sha mit 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 R OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 130 Do212h.in Lane /�o�eat0",3t .Ruann.i,3Roat, Ta— .6. Owner: Date of Inspection: Inspectlon Summary: Check A,B,C,D or E/ L,� WAYS complete all of Section D �1 A. S stem Passes: t 1 have not found any information which indicates that any of the failure crittr))'a described in 310 CMR �I 15.303 or in 310 CMR 15.304 exist. Any failure criteria no( valuated are indicateeibelow. Comments: Thp &aj&2age zu•5tem .is .in /2aopea woak.ing .oade� a.z< .the '% Q 7 0 A e n B. System Conditionally Passes: A,Al 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. ,,IlWe,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: Ad 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 pipes)are replaced obstruction is removed distribution box is leveled or replaced ND explain: tiy 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 Page 3 of 11 ' OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Ro gent No z in o 12 to Lane Owner: Qe-st Hyann.c,5/2o2 , a s.6. Date of Inspection: C. Further Evaluation is Required by the Board of Health: �� Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health,,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health,safety and the environment: A-t Cesspool or privy is within 50 feet of a surface water ,f 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: e 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. 4!2 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. V The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. oo The system has a septic tank and SAS and the SAS is less than 100 feet but 5 feet or more from a private water supply well". Method used to determine distance f "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. Other: 7h.L3 iz a .6ewage zyztem. The AuAlem conz jztz o f 2-6 'X8' 9-Pock ce�saaooiz and 1- 1000 ga.e.Pon �2eca,st .Peach.ing pit See Rage 10 3 1 Page 4 of 1 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 130 Do.2 h.in Lane Glee yann.ce1oic , Nazz. Owner: /loge/L; ftlL-in Date of Inspection: 6/ 3/0 3 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ ackup 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 h day flow _ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number f times pumped--L.y 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. �tny 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 form.] 45)d (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 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. 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 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 11 of a public water supply well W. 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 I 1 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 130 Do.P12h.in Lane e a , azz. Owner: Rogea.t 111377a ' Date of Inspection: 3 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 ? v Were all system components, Y p cluding the SAS, located on site . A" 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)) 5 Page 6 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:130 Do212h.in Lane UgAi_ H�anni�sLo?t. �la.s�5. Owner: Ro&e2t Moa.in Date of Inspection: 61,43103 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design); Number of bedrooms(actual): v� ) DESIGN flow based on 3li C 1 g 5.203 for example: 110 d x#of bedrooms : Number of current residents: Does residence have a garbage grinder(yes or no):/ES Is laundry on a separate sewage systemes or no):.J.,b [if yes separate inspection required) Laundry system inspected(ves or no): X,5 Seasonal use: (yes or no) Ye'5 Water meter readings, if available(last 2 years usage(gpd)): 2001=30, 000 ga e eon.=8 z, 20 qPD Sump pump(yes or no): LZ 2==-15, 210ga iio n.6=9 6. 5 8 gP D Last date of occupancy COMM ERCIAL(INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): d Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no): 60 Industrial waste holding tank present(yes or no);� Non-sanitary waste discharged to the Title 5 syste (yes or no);,i�� Water meter readings, if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Q 11d� L Source of information: CJAid � Was system pumped as part of the inspection(yes or no): _ If yes, volume pumped: Q gallons-- How was quantity pumped determined? Reason for pumping: 1110 TYPE OF SYSTEM ,V Septic tank,distribution box,soil absorption system Z Single cesspool Overflow cesspool 1, 4�2 Privy / 0 Shared system(yes or no)(if yes, attach previous inspection records, if any) 03 Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ,Tight tank ,VJ Attach a copy of the DEP approval !YpOther(describe): 160 A roxim tea of all co orients date stalled(i own)a d our a of information: ss,�yt Were sewage odors detected when arriving at the site(yes or no): A14' 6 Page 7ofII OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: Do.212h.in Lane e,6 yann.c-6po2 , l7aea. Owner:Rofezt ft.,zin Date of Inspection: 61A 3/73 BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron _ 0 PVC4Jother(explain): .dam Distance from private water supply well or suction line: .! }� Comments(on condition of joints,venting, evidence of leakage, etc.): �o jnt.t ri?i2Pna 11 ah# Nn Pyid nro o4 Leakage The 6U,6te4 i,s vented thorough .the house ventz. SEPTIC TANKr(-�i.A+ 4ocate on site plan) Depth below grade: 4.)h Material of construction:4,i concrete t4ldinetal//ifiberglass, L olyethylene .ff54other(explain) AO If tank is metal list age:4A Is age confirmed by a Certificate of Compliance(yes or no);, /9(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: �G%A Scum thickness: 40 Distance from top of scum to top of outlet tee or baffle:_'40 Distance from bottom of scum to bottom of outlet tee or baffle: AA How were dimensions determined: 114 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): So�nf1r funk ;A nnf anI . Pvmn • fhP ran.n rP.+.snnnZ annuaeXy, Ga29age <)ULPI fog iA in olPnrP CPAA.1;,nnp.t riav .�fn ir><unnDl/y .tn i / rli%p3a0 i,6 �z2ehent. GREASE TRA&�d(locate on site plan) Depth below grade: Material of construction:,V4concrete/j?,L4tnetal.t?dfiberglassl:,�4polyethylene. other (explain): /110 Dimensions: 64 r_ Scum thickness: 16W Distance from top of scum to top of outlet tee or baffle: 11 9 Distance from bottom of scum to bottom of outlet tee or baffle i9 Date of last pumping: .61)4 Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): G2P_a/6P t2a12 i,3 not 2eeent. Page 8 of 1 I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:130 Do.2l2hin Lane Glv.s.t uanni eR"O/tt, Naez. Owner:Roge2t No zin Date of Inspection: 6 3103 TIGHT or HOLDING TANY S-(tank must be pumped at time of inspection)(locate on site plan) Depth below grade:_JA Material of construction: concrete 4metal zQ fiberglass&jl polyethylenel.,)4other(explain): Dimensions: Capacity: allons Design Flow: allons/day Alarm present(yes or no): Alarm level: A�4_ Alarm in working order(yes or no):W Date of last pumping: Comments(condition of alarm and float switches, etc.): 71 Qht oa hoiding .tankh ace no p2ezen . DISTRIBUTION BOX: Zif present must be opened)(locate on site plan) Depth of liquid level above outlet invert;lk— Comments(note if box is level and distribution to outlets equal,any evidence of solids carryove.r, any evidence of leakage into or out of box,etc.): '6s ,z gution vox ha.3 two iate&ai,6. No evidence o f eoiidz ca22y ove2. No. evidence o,e .Peakage into on out o e 9ox. PUMP CHAMBEPA&/e (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.): 10ilm,Q rhnm0. on JA not nnvAvnf _ 8 Page 9 of I I OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 130 Do.2l2h.in Lane .lie,6t Kuann.i sRo2t, t7a s.s. Owner:Ro.ge2t o_. cn Date of Inspection: 61,13103 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan,excavation not required) 2-6 'X8' B-Po c ce.e.6/2ooi.6 and 1- 1000 ga teon /22ec azt ieach.ing 12.il_ If SAS not located explain why: Located: See Rage 10 Type 4/ leaching pits, number: 1f�'>leaching chambers,number: O leaching galleries,number: 6 leaching trenches,number, length: O caching fields, number,dimensions: Q overflow cesspool, number:� ' - .),D_ innovative/alternative system Type/name of technology:A)t', /Q�S lees^i�ar 71Wei 7N Comments(note condition of soil, signs of hydraulic failure, level of ponding,damp soil,condition of vegetation, etc.): Loamy .6and to goney Zine zand. No zignh o7_0 hydItau—tic , ai.euae o2 _ on .cng. ortz ate 2y. Vegeta con .ch no2ma ab e wa e2 74 ge.eow the .invent /2.i/2e o e eaching /2.c . CESSPOOLS: /(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inle:j invert: Depth of solids layer: Depth of scum layer:_ Dimensions of cesspoolf Materials of construction: e_,;i, G Indication of groundwater inflow(yes or no): Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): Same a.6 agove. PRIVY (locate on site plan) Materials of construction: Dimensions: 9 Depth of solids: Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.): P/t-ivy .i.s no.t_ �2e�ent. i 9 Page 10 of l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Prop erty Add ress: 130 7o.Pahin /rin0 Owner: /2o Peat mo�c.in Date of lospectioo: A/A3/n 3 SKETCH OF SEWACE 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 publie.vter supply enters the building. 0 , 10 ,� i z 0 i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE OlErtifirate of (90MI11junrE THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX� by..........J.P.Macomber Jr. ................................................................................................................................:...........:............................................... y .... �...SIpS?�r. .,Ma. .s..,....... . at .......... .39....D9. p.h. I�....I,�atle....�!1e.s.t.. H .an.. i. ....................................................................................... has been installed in accordance with the provisions of TITLE 5 aThe State Environmental Code as described in the application for Disposal Works Construction Permit No. THE:ISSUANCE OF THIS CERTIFICATE dated ............. . . SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE 4"1 ............................... Inspector ................ .....�... THE COMMONWEALTH OF MASSACHUSETTS ' BOARD OF HEALTH TOWN OF BARNSTABLE FEZ...$...3�.:.�0 3�i��rn�tt1 urk,� f�urt�#r�rr#iun �lermi# Permission is hereby granted........J.P,MaC Ombe r Jr. ............................................................................................................ to Construct ( ) or Repair ) an Individual Sewage Disposal System at No......13.9...DG27-Phj.1..1...Lane West . I port,MaSS .......... ........... ........................................................... street 2 as shown on the application for Disposal Works Construction Permit No..9 _5'- Dated..............:. .............................1.1z................................................... DATE................ ............................................................... Board of Health � rORM 36508 HOBBS a WARREN.INC.,PUBLISHERS Page 1 I of 11 OFFICIAL INSPECTION FORM— NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEW.kGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:130 Do.Pl2h in Lane &)'e.3t Hyanni.6/2oat, mahz. Owner.Ro&eat No2.in Date of Inspection: 61,13103 SITE EXAM Slope Surface water Check cellar Shallow wells r Estimated depth to ground water 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: L_',*_0 3F Observed site(abuning property/observation hole within 150 feet of SAS) D Checked with local Board of Healh-explain: AJ4 Checked with local excavators, installers-(attach documen Lion) Accessed USGS database-explain:. (L;�l �T�j,1g You must describe how you established the high round water elevation: IZ.aed: Gah1tetu & Miieen Node-012/1094 gaound watez etevat.ionz agove hea Peve.P. LLzed: LLSGS: 09.6e2vat.ion we.P.P data. Used: LLS Torhnlrop ofln 92 000 1 Piate #2 Annua.P ,zangez o 2oun .Po))rj1 n,3 �rjnualzu 1992 Leaching �� Pit g6 ;eet Groundwater: Feet Below Bottom of Pit High Groundwater Adjustment 1.8 ft per Frimpter Method ncrefore, the vertical separation distance between the bono Of the leaching pit and the adjusted groundwater table is feet. 11 , II • Rnr+ -n•��-r�- 'r►.-wn•n��-r.�rwrrerRrn.++.�►r r�r�v • !'OWN OF BOARD OF HEALTH 0 1 on,SUI;SURFACR SFWACF DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION I•••t•y��••,••. —T.tta.".�rnA+rw,'.f.7+n rlRlee9swlR:rt'I rlvf.11�flR�1—TAr�I1 1A'1R� ro" ,.ae-t-r•r--�. •—..^ -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRES$ 130 doiphin Lane blest Kyann.izpo2t, flazz. ASSESSORS MAP, BLOCK AND PARCEL OWNER' s NAME IR"e`t M04.i n PART D - CERTIFICATION NAME OF INSPECTOR Joseph P.Macomber .Jr. COMPANY NAME J P Macomber & Son Ind".` COMPANY ADDRESSBox 66 Centerville,Mass. 02632 Street To►m or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 -1 57-8 w CERT'IFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and omplete as of the time of ,inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems , Check one : ]/1System PASSED , The inspection trhich I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 - 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. System FAILED* The inspection which I have con acted has found that the system fails to Protect the jiublic health and the environment in accordance with Title 6 , 310 CMR 16 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . M Inspector Signature Date ''�� copy of this ce If cation must be provided to the OWNER, the BUYER DC where applicable ) and the BOARD OF )iEAL711. If the inspection FAILED, thb owner or`00� erator shall u syste within one year of the date of the inspection, unless alloweddorthe requiredm otherwipe as provided in 3.10 CFjn 16 , 306 . partd , doc TOWN OF BARNSTABLE LOCATION 130 DJ i-)A,,, Lk, SEWAGE # VILLAGE U, A,(,,-,n;� j7r, j ASSESSOR'S MAP & LOT C�S l 7% INSTALLER'S NAME & PHONE NO. �J • J? J;yi�«vobc/-,fSLA SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) 1000 C2 a. NO. OF BEDROOMS - .PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: _la DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No {/ ICY Aa i O T NN°°''" APPROVED � �0.00 e�matON nervation Departme:)t Fxs............................ THE COMMONWEALTH OF MASSACHUSETTS ARD OF HEALTH Oencd Date TOWN OF BARNSTABLE Appliration for Biipniial Workii Tomtrurtion Frrutit Application is hereby made for a Permit to Construct ( ) or Repair NXX) an Individual Sewage Disposal System at: 130 Dolphin Lane West Hyannisport --• __ .................................................................... ---....---...-•--•••-•---........._..----------•----••----------•------•--•---•--.........__---... Location-Address or Lot No. .............................................................. ------.------------.------•-•----•-••-----•----_-------.---•.-----•---•-----------.--------------- W J.P.Ma e omb e r Jr . Owner Address Installer Address Type of Building Size Lot............................Sq. feet U DwellingX No. of Bedrooms.............3_............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type e of Building No. of ersons-_------------------------- Showers (� yP g ---------------------------- P ( ) — Cafeteria ( ) W Other fixtures ................•-•---•------•------• . W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid'capacity.....---....gallons Length................ Width................ Diameter.---............ Depth................ x Disposal Trench—No. .................... Width-------------------- Total Length.................... Total leaching area....................sq. ft. Seepage'Pit No----------------_--- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank a PercolationI cults Performed Test Pit No. nute p r nch Depth of Test Pit.................... Depth to ground water..---.........---....... r%4 Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........---..--.....---. W •-------•--------•-•----------•--------•••--•-•--•-••--•-•-•-•------•-•--------------•-•--•--•.....•......................................................... 0 Description of Soil...............................................................................----------------------------------------------------------------------------•-•-•-_•---- W Sand & Gravel U -----•••---•---•---•--••-•-•--••--•-•-----•----•------•-----••---•--••----•-----••--•-•---•-•-•--•-----•...-•----------•-•-•----•--......•-------------•••-......•..................................... W - ------- ------ ------- _ ------ , U Nature of Repairs or Alterations—Answer when applicable...--1--1000 ga llori YeaC Trig p 1 ... •----••-•-•---------••----•---•-------------•-----------•-----•---•-•--------•--•---•---•---••-•--•---•-•-•-•-•--•••------•--•-------••-•--•--•-----•-•----•--------•-----•--------•----•---.......---- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has b ensue by the b at f health. Signed .... -- ----------- -?..�� 1/22/92 �----------------------------- ........ ------.------------------ Date ApplicationApproved BY ...... .... ...� -------------------------------...................................... -d " � re Application Disapproved for the following reasons- -----------------------------------------------------------------------------....... - ----------------- ---------------------- .................................. .. ................. .. ..:......................................................................................................................................... ......... . ......................... Date PermitNo. ------9a.......2_ ?..5.................................... Issued ........................................................----------- Date No................................... FIc$...:L.3 n.:.`)r „ THE COMMONWEALTH OF MASSACHUSETTS �oJu--�'4BOARD OF HEALTH TOWN OF BARNSTABLE App ira#ion for Uispusa1 Works Towitrnrtion rrrmi.t Application is hereby made for a Permit to Construct ( ) or Repair)(X an Individual Sewage Disposal System at: ..1?0...D 1r?r;n...1"a). a.-kL( st••Hyanniam t.. "- .-",: Location-Address or Lot No. .............................................................. .................................................................................................. Owner Address 'I tT.,.P.Macombe...Jr Installer Address d Type of Building Size Lot............................Sq. feet aDwellingX-No. of Bedrooms.............3--_-__.----_-._--_-._-__-__-Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................. Showers ( ) — Cafeteria ( ) Other fixtures ------------------------------------•--•-•••-•••-••_..._ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter__-_____.._....- Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 94 •-•••••••-••--...---•••----•---•••••-••-•-••-•••-•-----•••-••--....-••••..............•-•---•-------......................................................... 0 Description of Soil........................................................................................................................................................................ U ................................................ _z.r d- & y ------------------•---------------------•------------------••----•--------------•--••---------......---..........._ W ------------------'--------------------------------------------------------------------------------------------------------------------- ---------------------------------------------•-------------------- U Nature of Repairs or Alterations—Answer when applicable 1_--1n0 s 0...a, . e. 11_on...1•oa c hr i_n cr.... +.- .- _. ---------------------------------------------------------------------------------..................................................•----•-•---•••--••-•-••----••---••-----••-•-•••••.......-•-.•..... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further, agrees not to place the Y p Sl ned -_- .- ��by the boar �f health. �'/ system In operation until a Certificate ofCompliance has beeniss�� r .' �/��Q? / Date Application Approved BY E l �1= .... �-_--------------------� ---------------------------------------- Application ( �d -- .........................-.-._.----__...... Date Disapproved for the following reasons- --------------------------------------------------------- --- ....................------.................................... ................................................ .. ..' ...........--------...... ---................---....----------....------. ...------------------. '-------- ......-.........--...................... q --" Date PermitNo. / 3.=�- ---------------------- Issued .................................................... ----- ------ =................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .-TOWN OF BARNSTABLE C�ertifi ate of (11araylia nre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired (XXX)C , b ........ Ma. '�r` T" Installer at ...-....--}? moo , ; �....La- : ,�_�. -....�i :�� s �r ..�*has s .....................................--------------------------------'....................... L 1n if Wept U �/ 1 1 V 1 has been installed in accordance with the provisions of'TITLE 5 obThe_�a;-e—Environmental 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 THE SYSTEM WILL FUNCTION SATISFACTORY. DATE......... .... 1....7.? 0- ...... .............. Inspector— THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �i��rr��1 �vrk,� Cn�an��rnr#inn rrntif Permission is hereby granted.........1C. LL� -_ -•---------------•------------------------------...------....•-•-.................... to Construct ( ) or Repair (yX) an Individual-Sewage Disposal System at No.......-:�Ln._nn.7.nhj n -r n Rna Street as shown on the application for Disposal Works Construction Permit No.... ..... Dated.......................................... •----------------•------•--- -----------------------------•--•------------ Board of Health DATE................•.•••---••---•--•••••--•----••-••-••••-•--••............•------- FORM 36508 HOBBS&WARREN.INC..PUBLISHERS