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HomeMy WebLinkAbout0017 EDWARDS ROAD - Health �rI Ttdwards Road Hyannis F ,F/R A A ='328 172 a � 6 FF� II 0 1 1 i I I dI d . e d 4 f Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14, 2012 required for every Y 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 filling out forms A. General Information on the computer, 1 use only the tab 1. Inspector: key to move your cursor-do not David D. Coughanowr, R.S. use the return Name of Inspector key. Eco-Tech Environmental Company Name 43 Triangle Circle Company Address Sandwich MA 02563 City/Town State Zip Code 508 364-0894 1328 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority May 14, 2012 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. M ****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. �1 Z) t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 'Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14, 2012 required for every y y page. Citylrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D 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: Inspector's Note==> The septic system described herein is deemed to pass this Real Estate Transfer Inspection if it does not meet any of the failure criteria enumerated in Section D on pages 4-5. The scope of this inspection is limited to health and environmental compliance and the septic system has been evaluated according to the conditions observed on the day it was inspected. No estimate or guarantee of system longevity is made or implied by a passing determination. 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 W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14, 2012 required for every y Y page. City/Town 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 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 t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ec^M 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14 2012 required for every Y Y , 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: 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 Q ® 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 l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14 2012 required for every Y Y 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 exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14, 2012 required for every y Y page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate "yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ N Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® El 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): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example. 110 gpd x#of bedrooms): 220 gpd t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14, 2012 required for every � Y page. Cityrrown State Zip Code Date of Inspection D. 'System Information Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 75 gpd 9 ( Y 9 (gpd)): Detail: 2010, 2011 Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14, 2012 required for every Y Y page. City/Town State Zip Code Date of Inspection 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): l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 P 9 P Y 9 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14, 2012 required for every y Y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Age: 9+ years. Certificate of compliance for new system was issued 10/2/2002 (Permit#2002-471 at Health Dept). Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 4 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.): Sewer line appears structurally sound with no evidence of leakage or backup into dwelling. Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: E 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: 10.5 x 5 x 6- 1500 gallon tank Sludge depth: 10 in t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14, 2012 required for every y Y page. City/Town 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 24 in Scum thickness 5 In Distance from top of scum to top of outlet tee or baffle 7 In Distance from bottom of scum to bottom of outlet tee or baffle 12 in How were dimensions determined? Design plan Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Pumping is recommended at this time, and maintenance pumping is recommended every 2-4 years thereafter . Tank and tees appear structurally sound and functioning as intended. No evidence of leakage in or out was observed. 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 l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14, 2012 required for every --y y 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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14 2012 required for every y y page. CityTTown 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 at outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box appears structurally sound with no evidence of leakage in or out. Few solids in sump. 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.): 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14, 2012 required for every y Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: 4 ® leaching galleries number: 1 ❑ 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.): Soils above leaching gallery appear unsaturated. No evidence of surface ponding, breakout, lush vegetation, or other evidence of hydraulic failure was observed. An observation hole was dug into leaching gallery stone and no effluent contact staining was observed in the stone or overlying soils. No standing effluent was observed in the top 1 foot of stone. 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 l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14 2012 required for every y y page. CityTTown 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.): l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14, 2012 required for every Y page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately QND 2 8, 41 -7 z� 3 2?' l <;E PT, c n_�oX n3LAOJ I � LZACRIQ6 GALu=RY t5ins-1 Ill 0 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 May 14, 2012 required for every y Y page. CitylTown 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: 11+ 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: 10/11/2002 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: Approved design plan on file with the Board of Health shows bottom of system to be 6.88 feet above the bottom of a witnessed test pit in which no water or groundwater mottling was encountered. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ., Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 17 Edwards Road Property Address William Hickman Owner Owner's Name information is Hyannis MA 02601 Ma 14, 2012 required for every Y Y 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Edwards Road Property Address Adam Lindsay Owner Owner's Name information is required for Hyannis MA 02601 05/28/08 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. . Important: A. General Information When filling out forms on the computer,use 1. Inspector: only the tab key to move your Brad J. White cursor-do not Name of Inspector use the return key. Bluewater Company Name 350 Main Street Company Address West Yarmouth MA 02673 Cityfrown State Zip Code (50.8)775-2800 Telephone Number License Number B.. Certification I certify that I have personally inspected the sewage disposal system at this addres and that'the F information reported below is true, accurate and complete as of the time of the,inspection. T� inspection was performed based on my training and experience in the proper function and mh enance of on ate sewage disposal systems.l am a DEP approved system inspector pursuant to ction 15r 40 bfl� Title 5(310 CMR 15.000). The system: --0, Passes ❑ Conditionally Passes, ❑ Fails --i ❑ Needs Further Evaluation by the Local Approving Authority 05/28/08 Inspector's Sign a Date The system ' Spector 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. lindsay T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 15 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM 17 Edwards Road Property Address Adam Lindsay Owner Owner's Name information is required for Hyannis MA 02601 05/28/08 , every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: 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: -W System fully meets pass criteria. Recommend pumping tank to remove solids 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 lindsay T-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System^Page 2 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments G M 17 Edwards Road ' Property Address Adam Lindsay Owner Owner's Name information is required for Hyannis MA 02601 05/28/08 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ distribution box is leveled or replaced ND Explain: The system required pumping more than 4 times a year due to broken or obstructed i e s . The ❑ Y q P P 9 Y PP ( ) system will.pass inspection if(with approval of the Board of Health); ❑ broken pipe(s) are replaced ❑ obstruction is removed ND Explain: C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system.is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health (and Public Water Supplier,if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1_of a public water supply. El The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. lindsay T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °M 17 Edwards Road Property Address Adam Lindsay Owner Owner's Name information is required for Hyannis MA 02601 05/28/08 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) C) Further Evaluation is Required by the Board of Health (cont.): ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. I. 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 El N. Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool 0 ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool El ® Static liquid level in the distribution box above outlet invert due to an overloaded l or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. lindsay T-5.doc^03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 15 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 17 Edwards Road Property Address Adam Lindsay Owner Owner's Name information is required for Hyannis MA '02601 05/28/08 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) D) System Failure Criteria Applicable to All Systems (cont.): Yes No ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate,nitrogen is equal to or.less than 5 ppm., provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The.system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply 0 ❑ 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. lindsay T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 15 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 17 Edwards Road Property Address Adam Lindsay Owner Owners Name information is required for Hyannis MA 02601 05/28/08 every page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? N ❑ 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 .El 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. ® 0 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)] lindsay T-5.doc a 03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments- M 17 Edwards Road Property Address Adam Lindsay Owner Owner's Name information is required for Hyannis MA 02601 05/28/08 every page. City/Town . State Zip Code Date of Inspection D. System Information 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): 239.76 gpd Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): o(`- I Ole 9,q (toa `'7— 113,01 CrDlJ Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): lindsay T-5.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Forma Not for Voluntary Assessments °M 17 Edwards Road Property Address Adam Lindsay Owner Owner's Name information is required for Hyannis MA 02601 05/28/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) General Information Pumping Records: Source of information: System has not been pumped 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: ONO�® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ (NO' 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): v 4 Approximate age of all components, date installed (if known) and source of information: System was installed in 2002 per as built plan of septic system Were sewage odors detected when arriving at the site? ❑ Yes ® No lindsay T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15 f - - Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments w 17 Edwards Road Property Address Adam Lindsay Owner Owner's Name information is required for Hyannis MA 02601 05/28/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Building Sewer(locate on site plan): Depth below grade: ---22" 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.): POP Building sewer is in good condition. No evidence of leakage. Used camera to check all exterior piping with no visible issues found.- Septic Tank(locate on site'plan): Depth below grade: feet Material of'construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No ----------------------------------------------------------------------------------------------------------------- Dimensions: 10'-6"x 5'-8"x 5'-8" (1,500gallons) ' Sludge depth: 6" • Distance from top of sludge to bottom of outlet tee or baffle 31 411 Scum thickness Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Measured lindsay T-5.doc•03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 15 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 17 Edwards Road Property Address Adam Lindsay Owner Owner's Name information is required for Hyannis MA 02601 05/28/08 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet and outlet tees are in good condition. Liquid level is normal. No evidence of leakage in or out of tank. Recommend pumping of tank. Grease Trap (locate on site plan): .Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): lindsay T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 15 Commonwealth of Massachusetts W Title 5 .Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 17 Edwards Road Property Address Adam Lindsay Owner Owner's Name information is required for Hyannis MA 02601 05/28/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑. Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): ow Distribution box is level with no evidence of solids carryover. No evidence of leakage in or out of box. Distribution box only has one outlet leaving it and is 18" below grade. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No lindsay T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 15 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 17 Edwards Road Property Address Adam Lindsay Owner Owners Name information is required for Hyannis MA 02601 05/28/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): .Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: leaching pits number: ---� ® leaching chambers number: leaching galleries number: ❑ 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.): Soil is dry. No signs of hydraulic failure. Vegetation is normal. No ponding. Chamber only had 3" of liquid in it. Chamber is 17" below grade. lindsay T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 15 Commonwealth of Massachusetts . ,Title 5 Official Inspection Form Subsurface Sewage Disposal System Form m Not for Voluntary Assessments �M 17 Edwards Road Property Address Adam Lindsay Owner Owner's Name information.is required for Hyannis MA 02601 05/28/08 every page. Cityfrown State Zip Code Date of Inspection Da System Information (cont.) Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑. No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding., condition of vegetation, etc.): lindsay T-5.doc•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15 Commonwealth of Massachusetts .Title 5 Official Inspection form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 17 Edwards Road Property Address Adam Lindsay Owner Owner's Name information is required for Hyannis MA 02601 05/28/08 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water upply enters the building. r _ �Ro eft' f I I t A aClAM, Al - 4 3�FCK .AZ - 26` z A-6- 2-T (3I 21 I�L>4 GOB , lindsay T-5.doc-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 15 60 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 17 Edwards Road Property Address Adam Lindsay Owner Owner's Name information is Hyannis MA 02601 05/28/08 required for y State Zip Code Date of Inspection every page. Cityrrown D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells 134"or 11'-2" Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: 1W ® Obtained from system design plans on record - If checked, date of design plan reviewed: P- 10/16/02Date ❑ 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: Iiiii, MIW 29/Zone C/Level 7.7/Adjustment 2.7 x 12" = 32.4" You must describe how you established the high ground water elevation: - Do, Design plans for system have test hole with no indication of groundwater @ 134". Bottom of the s.a.s. is at 53". If you add the required usgs adjustment of 32.4" brings your total to 85.4". This leaves at . least an additional 48 6"of additional seperation lindsay T-5.doc-03108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15 I I I I I I I I I i i f hi L I - t - --- t i 1 I -._.._ ' --; i f I I- -, i. , .L.- -����� •� 1 -.1 i 1 �_f .., , � .i.� S��.� i I I I .•� `.ti` _ t l I r ' �� i ICI➢ i_i 1 I L± "'''T � �.I I � I ----�-- I ---I I I I---I - --- --- - I { ' I I I I : IAL��+.; .. a _w... --- - -L_ -- - I -- ----I- I I I It iT�—_ I I I I i /1A4 -- I- --II--,-�I I ,i Ii I I ' ' I '------- Ls I - _ I I I I I , 1 i I I I I i I I i I -- TcSf _._. 1 N•.D.._ C.oTFS I------------ - ' O.F'1 &P.0% N®v.:_�A`4`�'Li_ 1 I �►r l�jd`r?Urn- ©F_ 5. 4._`a i 5 5'3 ,- - - - - - --- -:-- -t- -- ; I I i l LIT xn ti I I I I i ,�� I _._._ - � �I 4 .. i I 1 - _ _.! , � I I i I i I I 1 I f I i 1 ! t Town of Barnstable do Regulatory Services saxxsrnsz a Thomas F. Geiler,Director 9�At039. ��� Public Health Division rFD MA'I A Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 REGARDING SEPTIC INSPECTIONS BY PRIVATE CONTRACTORS DISCLAIMER This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original or copy of the report; this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observations and interpretations contained within this report. In addition, by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would be listed on the "Disposal Works Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. I QASEPTIC\Disclaimer Private Septic Inspections.DOC TOWN OF BAMSTABLE , LOCATION �7 SEWAGE # -7O�' VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �t�� 1l (size).­3-VAd osvC NO. OF BEDROOMSQCc�l�s�/>�t�� �o 't�` C�.�Aa ?,J' BUILDER OR OWNER PERMITDATE: Ido X 1 COMPLIANCE DATE: a Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility / Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) / Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) �� Feet Furnished by i y Fee O-� ACH I:TT Entered in computer: THE COMMONWEALTH OF MASS US S Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipprication for Mtgpogar *p5tem Con6truction 3permit Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. 0,;, .. eC`&0",e ���/4 �. /;p oii('o'i 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 -7 3 9- > gallons per day. Calculated daily flow 0 gallons. Plan Date 9 -2 a' ®d' Number of sheets , Revision Date Title Size of Septic Tank 13"`0 o bq-C�r Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) 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.W by this Board of Health. Signed Date Application Approved by jV. _= r nn Date Application Disapproved for th following reasons Permit No. Z 00 a_-q-7 I Date Issued 161d En No. i2_ kr. ; to r td Entered in co� � "� � \ mputer: y< THE COMMONWEALTH OF MASSAdiUStTTS " Yes PUBLIC HEALTH DIVISION..-TOWN OF BARNSTABLES MASSACHUSETTS Rpprication for Migoozar *pztem Con�truc ion �AernY%t ' Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Complete System''n Individual Components Location Address or Lot No. j, 1p,6 Owner's Name,Address and Tel.No. Assessor's Map/Parcel /'"Z Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. jr J' .7,��'�� f Type of Building: `! Dwelling No.of Bedrooms CZ q. g ( ) l_Lot Size ft. Garbage s Grinder Other Type of Building /r%'f No.of Persons Showers Cafeteria( ) _ Other Fixtures Design Flow~ 3'. gallons per day. Calculated daily flow o gallons. Plan Date 9—-2 CP- 00Z Number of sheets I Revision Date Title Size of Septic Tank -'5-0 G jr- , Type of S.A.S. 3"X .gar 5- Description of Soil i Nature of Repairs or Alterations(Answer when applicable) ' Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of Health. Signed Date Application Approved by i/, ni . ----- Date Application Disapproved for th9following reasons r Permit No. Date'Issue,�p 11,1. J THE COMMONWEALTH OF MASSACHUSETTS C __ _ ---BARNSTAI3LE MASS-, MASS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed(\>e)Repaired(. ^)Upgraded( ) Abandoned( )by at _`> has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No. 2 ua7- L 7/ dated Installer Designer The issuance of this permit shall not be construed as a guarantee that the syst ' will fu ction as desi'-ned. Date I N !i to Inspector YR -----�----------------------------------- No. �,V�/ j Fee THE COMMONWEALTH OF MASSACHUSETTS ? PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS lwiopogal *pgtem Couotruction \Wernnt Permission is hereby granted to Construct(4?�)Repair( )Upgrade( )Abandon( ) System located at •�`J �'�(? �/' t7 y/t�'�'/. - 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 o. his-permit. Date: I 011(LO-Z, Approved by TOWN OF BARNSTABLE I LOCATION -7 .e`OG��d_l 0P,0 SEWAGE # -Z oO-Z VILLAGE .�jl�'�'�.n ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. s SEPTIC TANK CAPACITY LEACHING FACILITY: (type) — (size3 NO.OF BEDROOMS -2 BUILDER OR OWNER Le PERMITDATE: o COMPLIANCE DATE: o a Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) _ i Feet Edge of Wetland and Leaching Facility(If any wetlands exist y • within 300 feet of leaching facility) Z Feet Furnished by L7> i 14 je s 3 3 f SAMPLE Bk 15746 Ps90 090427 DEED RESTRATrCh- - 1071-16-2002 & 11 =39a WHEREAS,1 l tuL of O �.J r `l� _S 'RD MA (owner's name) (address) is the owner of III P ( j.g located at (address) l ' MA (hereinafter referred to as ) and being shown on a plan entitled "Subdivision of Land in .4 %Ouk'5 MA, Property of et al, duly recorded in Barnstable County Registry of Deeds in Plan Book , Page ; WHEREAS, An4 s the owner of said lot has agreed with the Town of (owner's Mealth Barnstable Board of o a restriction as to the number of bedrooms which can be included at this property as a pre-condition to obtaining a building permit for this property; WHEREAS, the Town of Barnstable Board of Health, as a pre-condition to — author zip ig the issuance of a building permit for the construction,of a single family home on this lot is requiring that the agreement for the restriction on the number of bedrooms in any house constructed on the lot be put on record with the Barnstable County Registry of Deeds by recording this document, NOW, THEREFORE I "r�am oes hereby place the following restriction on (ow his above-referenced land in accordance with his agreemenf with the Town of Barnstable Board of Health, which restriction shall run with the land and be binding upon all successors in title: 1. /7EPJ. ,2p;►2( y have constructed upon this property a house containing no (address) more than — — ( ) bedrooms. 2. agrees that this shall be permanent deed restriction (owner's name) affecting -} located onn � �, Q .,�,�.i MA, and being shown on the plan recorded in Plan Book , Paged i For title of Q ee the followin eed- Bo 5, s Page T (owner's name) Executed as a sealed instrument this day of. M LedrjOHN RNSTABLErc�EEgS EO STRY O- RUE COPY,ATTEST (date) F,M A4 � IS°r � BARNSTABLE REGISTRY OF DEEDS ASSESSORS MAP : TEST_ HOLE LOGS PARCEL : -- -- �1 FLOOD ZONE : SOIL VALUATOR : aNI 'Fj. ��IA� �y (61C4 � _ - --- WI TNESS: II�� i1�1�1►rki.L�1'�lb �I�VL/ �� REFERENCE ./� (� I' �I� l !��/ DATE: PERCOLATION RATE: TH_ I TH-2 � �,t_` �` � -(.�._ pL__. J-lei �J LOCATION MAPC wow, Gn 0 lip SEPT I SYSTEM DES I GN key FLOW ESTIMATE - -- BEDROOMS AT GAL/DAY/BEDROOM -G� GAL/DAY17 ------- ------_._— _ ' I SEPT I�C TANK —L\ 0 0 O ` \. (SAL/DAY x 2 DAYS - SAL __ y I%_ _ i '-RC�I�-� hJok_ _�" � ----- USE 1500 GALLON SEPTIC TANK 1 _. �Q OIL ,ABSORPTION SYSTEM ZL, -SIDE ARE- ?•�� � !� I►^ _ 4 .. ,r '7 X —' '--- N - BOTTOM AREA: s r J h• "a s ,_ yE I\ J. FT I C ;;;SYSTEM SECT I ON �� 5, _ ( t-C b� -_1 W11k nor _ VA O .` r D- GAL SEPTIC TANK i fu �rqpj r tK of - 37, b ,, u�v� +�joTlbP� �� � � �`�U�i eo, v,.__ 11ZL r'•;:...- ..-...._--'" ..../'� //h 11 p AMA ... SITE AND SEWAGE .PLAN ( LOCATION PREPARED FOR : i P V l fir, W v. SCALE: I i a 0 ------- DAV I D B . MASON Jk5 DATE: DBC ENVIRONMENTAL DESIGNS W DATE HEALTH AGENT ' EAST SANDWICH . MA ( 508 ) 833- 2177 W Z