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Home My WebLink About0043 ELDRIDGE AVENUE - Health L DRIDGE AVE. NIS 92 193 I t , o i f t Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 02601 11-10-2013 _ page. Cityrrown 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, use only the tab 1. Inspector: key to move your cursor-do not Jeremiah J Richmond (/ use the return Name of Inspector key. Richmond Sand and Gravel, Inc Q Company Name P.O. Box 902 Company Address Manomet MA 02345 City/Town State Zip Code 508-224-2231 S1 13647 Telephone Number License Number B. Certification 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 Appr ority 11-20-213 ctor'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 Title 5 Official TinspecinSubsurface 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 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 02601 11-10-2013 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: heck Acomplete B C D or E always all of Section ion 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: At the time of inspection the system meets all applicable Title 5 criteria. 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. i 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 17A Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is Hyannis MA 02601 11-10-2013 required for every y 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 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 l5ins-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 °wM 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 02601 11-10-2013 page. City(rown 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 ❑ ® 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 El ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/Z day flow t5ins-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 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 0260.1 11-10-2013 page. Cityrrown 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: 0. ❑ ® 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 El El Area 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 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 43 Eldri9 a Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 02601 11-10-2013 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? ® ❑ 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): 4 Number of bedrooms (actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 440 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ° M 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 02601 11-10-2013 page. Cityrrown State Zip Code Date of Inspection D. System Information Description: This system is comprised of a 1000 gallon septic tank, distribution box and leaching area. Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d 58 GPD 9 ( Y 9 (9p ))� Detail: See attached water consumption report obtained from local Water Department. Sump pump? ❑ Yes ® No current Last date of occupancy: 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: l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is Hyannis MA 02601 11-10-2013 required for every H 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: owner of record 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 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 02601 11-10-2013 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: 5-25-2001, taken from as built plans obtained from the local BOH. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 1.5feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 16 feet Comments (on condition of joints, venting, evidence of leakage, etc.): All interior piping appears to be in satisfactory condition, there is no evidence of any sewer leaks or odors. 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: 5.5' x 8.5'x 6' Sludge depth: 3„ 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 Subsurface Sewage Disposal System Form -Not forVoluntary Assessments 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 02601 11-10-2013 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 29 Scum.thickness 4" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 16" 'How were dimensions determined? measured in field Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): The inlet and outlet tees are present and in satisfactory condition, the static liquid level is level with the outlet invert indictaing that the septic tank is structually sound and not leaking. The contractor recommends routine pumping of the septic tank, approximately every 2-3 years and the installation of an outlet tee filter. 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 02601 11-10-2013 _ page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete El metal El fiberglass El polyethylene El other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes El 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 M 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 02601 11-10-2013 page. Cityrrown 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 01. Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box etc.)' ) The distribution box appears to be level and in satisfactory condition, there was some solids carryover from the septic tank, the static liquid level was level with the outlet invert and there is no evidence that it has ever been above this point. 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: y t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 02601 11-10-2013 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ® leaching chambers number: 3 -4'x 8' w/leaching stone ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): The leaching chambers were uncovered and inspected, there was 9" of static liquid in the bottom of the leaching system, there is evidence of staining another 8" higher than this point which is 7" below the inlet invert, there is no evidence of hydraulic failure at this time. There is also no evidence of ponding or damp soil and all vegetation appears to be consistent throughout the yard. 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 t5ins-11/10 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System-Page 13 of 17 I Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 02601 11-10-2013 page. Cityrrown 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.): t k i l5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 it L f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 02601 11-10-2013 page. Cityrrown 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 t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 02601 11-10-2013 page. City/Town 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+ 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: High ground water was taken from the previous T5 report on file at the local BOH. j Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 43 Eldrige Avenue Property Address Maria Mainini Owner Owner's Name information is required for every Hyannis MA 02601 11-10-2013 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information —Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Date: 11/22/2013 �J � eter Readi. H!.1.O Pagel of 1 o Customer 0 603914-1 Premise 0 603914 Q Service:Water-Regular Metered 1), ' N METER READING TRANSACTION INFO 0N0 Read Date Seauencell M ter# Faoe Sort Read Code R i Consumption Skin Count Iy Status Bill Peri Trans Oate 09/25/2013 Of 62003342 0 22020150 1 2,506 47 0 REG A R 201304 1010312013 0612MO13 01 52003342 0 22020150 1 2,459 58 0 REG A R 201303 0710312013 0312912013 01 62003342 0 22020150 1 2,401 57 0 REG A R 201302 04/0312013 12/2612012 01 62003342 0 22020150 1 2,344 53 0 REG A R 201301 01M212013 09125/2012 01 62003342 0 22020150 1 2,291 59 0 REG A R 201204 10IMO12 06/27/2012 01 62003342 0 22020150 1 2.232 61 0 REG A R 201203 07MW2012 ME 03126/2012 01 62003342 0 22020150 1 2,171 48 0 REG A R 201202 04l0412012 CIO1212712011 01 62003342 0 22020150 1 2,123 44 0 REG A R 201201 01104/2012 `}" 09127/2011 01 62003342 0 22020150 1 2,079 63 0 REG A R 201104 10/0512011 w 06/29/2011 01 62003342 0 22020150 1 2,016 44 0 REG A R 201100 07/0412011 03/28/2011 01 62003342 0 22020150 1 1,972 34 0 REG A R 201102 0410612011 C/� 1212912010 01 62003342 0 22020150 1 1,938 39 0 REG A R 201101 01IM2011 r. z 10108/2010 01 62003342 0 22020150 1' 1,899 114 0 REG A R 201004 1012112010 } 07=2010 of 62003342 0 22020150 1 1,785 65 0 REG A ' R. 201003 0710912010 x 0313112010 01 62003342 0 22020150 1 1,720 20 0 REG A R 201002 04/14/2010 01/05/2010 01 62003342 0 22020150 1 1,700 23 0 REG A R 201001 0111312010 10/01/2009 01 62003342 0 22020150 1 1,677 53 0 REG A R 200904 1010712009 0710612009 01 62003342 0 220 20150 1 1,624 44 0 REG A R 200903 07/3012009 0313012009 01 62003342 0 22020150 1 1,580 21 0 REG A R 200902 06129/2009 12/30/2008 01 62003342 0 22020150 1 1,559 48 0 REG A R 200804 12/3012008 0913012008 01 62003342 0 22020150 1 1,511 193 0 REG A R 200803 0913=005 06/30/2008 01 62003342 0 22020150 1 1,318 81 0 REG A R 200802 0613012008 041O 2008 01 62003342 0 22020150 1 1,237 39 0 REG A R 200802 04/0412008 Cn cn 01/0712008 01 62003342 0 22020150 1 1,198 42 0 REG A R 200a01 01107/2008 0 1QAW007 01 62003342 0 22020150 1 1,156 106 0 REG . A R 200704 1010312007 Cn m 07102/200 7 01 62003342 0 22020150 1 1,050 68 0 REG A R 200703 071002007 LO 04JO412007 01 62003342 0 22020150 1 982 35 0 REG A R 200702 04l0412007 m 0110212001 01 62003342 —0 222020150 1 947 210 n REG A R 200701 01/02/2007 N C'7 O N CV CV ` AsBuilt Page 1 of 1 TOWN OF BARNSTABLE LOCATION y3 41 a Au a SEWAGE# 3 a 3 VILLAGE 141V Qnn 11 ASSESSOR'S MAP&LOTS 9-- INSTALLER'S NAME&PHONE NO. D6tn50f) ke hCl '77J -377 SEPTIC TANK CAPACITY 1004D LEACHING FACILrIT:(type) A M k0 fJ (size) y 6T8 NO.OF BEDROOM ® BUILDER OR OWNER FAG uj i5 PERMIIDATE: JT-aS-0 r COMPLIANCE DATE: G- 7d-d) 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 facifi Feet Furnished by f3AcK of Ho�32 p � o a 0 a http://issgl2/intranet/propdata/prebuilt.aspx?mappar=292193&seq=1 11/13/2013 TOWN OF BARNSTABLE LOCATIONN3 g/dt r d 3 0- Ave. SEWAGE # VILLAGE 1411 gn l IJ ASSESSOR'S MAP & LOTE29-j- . INSTALLER'S NAME&PHONE NO.-RDA 1nson 2P t iy 77s' 4-774 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) A M 641 1-0 (size) NO.OF BEDROOMS BUILDER OR OWNER 1 �� PERMIT DATE: 5",?eT'0 I COMPLIANCE DATE: i 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 /ll 0 u� 0 k�0 o � 6 0 y, � LOCATION SEWAGE PERMIT NO. 4-2> ,��opely W LAGE 1NSTA LL/ER'S NAME & ADDRESS , BORDER OR OWNER DATE PERMIT ISSUED _77 DATE COMPLIANCE ISSUED � _Al77 r ,� �o �� 6� �; R 0�,� `� J No. Fee$50 / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ✓ PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes 01pprication for 30fgpo2;a1 *pgtem (Congtruction permit `9 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. 43 Eldridge Ave. , Hyannis, MA Terry Lewis Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil; Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 leach system consis— ting of a D—box and 3 precast leach chambers with stone all aro-tend. 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 d by this and ealth Signed Date 0 Application Approved by Date Application Disapproved for the following rea &' Permit No. '" Date Issued r No.jO2/� Fee$50 / THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS 0(p Yication. for Migogal *pgtem Congtruction Vertu ! Application for a Permit to Construct( )Repair( Upgrade( )Abandon( ) El Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 43 Eldridge Ave. , Hyannis, MA Terry Lewis Assessor's Map/Parcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 4 ,, Lodz�;� t Garbage Grinder( ) Other Type of Building No. of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallonWper day-�Ea�c lated�,daifiy;�floy gallons. Plan Date Number oflheet's t tR�lion Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Tit4e-5 leach system consis— ting of a D-box and 3 precast leach ch e-z ith stone all around. l) Date last inspected: t 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 Environm ntal Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this ar f Health Signed Daie Application Approved by Date Application Disapproved f r the following rea n f} 1 .r Permit No. "" /� Date Issued I ---------------�----------------------- THE COMMONWEALTH OF MASSACHUSETTS Levis BAR�NSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the,vOn-site Sewage Disposal System Constructed( )Repaired( X )Upgraded( ) Abandoned( )bm. E. Robi t�son Septic Service at 43 Eldridge Ave. , 1%,annis has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit N .. ated Installer Wm. E. Robinson Sr. Designer The issuance o.this permit shall not be construed as a guarantee that the s t will function as Date Inspect No. Fee$5 THE-COMMONWEALTH OF MASSACHUSETTS PUBLIC HtALfi4 6'iV1SI0N-- BARNSTABLE, MASSACHUSETT-S- f � Lewis Migpogal bpgtem Congtruction Permit Permission is hereby granted to Construct( )Repair(X )Upgrade( )Abandon( ) System located at 43 Eldridge Ave. , Hyannis 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 b!comple d within three years of the dateof s-pe �rt`1 Date: Approved by ti. f rf i ups NOTICE: This Form Is To Be Used For the Repair Of Failed Septic Systems Only. CAR rIFIC�►TION OF SKETCH AND AP'PLIC.+►TiON FOR A DISPOSAL WORKS CONSTRUMON PEI Wff DESIGNED PLANS) William E. Robinson,S%vreby certify that the application fir disposal works consuucxion permit A pedby me dazed $"vim C� / ,Concerning the property leveed at 43 Eldridge Av�D , Hyannis meets all of the following criteria: • The failed system is come=d to a ttddeatiat dwelling only. There are no commercial or business uses assorted vA*the dwdFm& / - • The soil is classified as CLASS i aqd Ike percola ion rate is tree than or equal to 3 minutts per Intl►- . There are no wetlands wltmn 10?feet of tic proposed scpttc ati-stem • There am no pnvate wells wuhw 15t1&a ut the proposed 9eptw S}vcru • There is no lnamase in 8owo ndkc change to me proposed • There are no variances or needed • T bnuom of tie "M bahty►aril[apt—be iocamd less than five feet above the etta.�mu I adjusted table devmioti[Adjust the Btmundwater table using the Frimptor method when • If the S.k&will located with 250 feet of any wetlands.the bouom of the proposed l�hing manna be located less than fourteen 1141 fe a above the am-drattnt adjusted grotmdcvater table elevation, Please m apkee the foilaw wi ,, A) Top of Giound StttFroc (Uimg GIs itdonttation, B) G.W.Elevation +the MAX. Hio c.W- t DIFFERENCE BETWEEN A aad B �� SIGNED: DATE: [Sketch pmposed plea of system on backl- W be"fokkr L-cn 1 'r t - ,t � ��..3��,.��':� � S E rip.ati"�'-��. �*�-�..x"'n�.t,ds �;.�'�- ;��`'��"a+m' �.. -�rr�.��-�"�-'��'�;• �S'S� ° �'��'�A.C��4c` :'dl! ,€i�� i ;��`ss. .. ; ayrt_`�``�s � � .a., -c�^r .. F 's.r,-,'rt`.sew, s�. '2- '�'�-•��,.'6, .,+,. I�m.ma q�� f"," i"t` F'rR�?�b "Y�� -ia_T? .. s, TOWN OF BARNSTABLE LOCATION 413 E 43 0- A v 2. 'SEWAGE # VILLAGE li CkA/),S ASSESSOR'S.MAP.& LOT INST4LLER.'S NAME&PHONE NO. JR06in5oo �CP Fic.� -77:V •$7, SEPTIC TANK CAPACITY LEACHING FACILITY (tYPe , � ) I J m f.}' (size) y 467_; 7777777 NO, OF BEDROOMS k . BUII DER`OIZ OWNER 1 e U.) I S PERMITDATE �S C�J COMPLIANCE DATE: o c7) 41 Separatidn.Distance.Between.the Maumum Adjusted Groundwater Table and Bottom of Leac ng Facility Feet A Pnvate WaterSupply Welland Leaching Facility (If any wells eztst { on`site or within 200 feet:.of leaching facility) Feet Edge..of Wetland and Leaching Facility:(.If any wetlands exist r within 300 feet of leachung.facility - 'Feet:. Furnished by /1l ? h,- 1 /o/ W _ X � j. Q � C•S O �Scoy . jo >�7d� -\ COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 43 Eldridge Ave. yannis Owner's Name: Terry Lewis Owner's Address: same Date of Inspection: ems. Name of Inspector: (please print) Wi 1 1 i am E Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1089 Centerville, MA Telephone Number: (508) 775-8776 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to S on 15.340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority 'Fails D/ Inspector's Signature: ) /�/` �-�vL� Date: - o I The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of HeaRh 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 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 43 Eldridge Ave. yannis Owner: Lewis Date of lnspection:,t-;t. G — P, Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy em 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 rep ired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Ans er yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please expl in. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unso d,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the exis g tank is replaced with a complying septic tank as approved by the Board of Health. *A etal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance ind'cating that the tank is less than 20 years old is available. N explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or o structed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with a roval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced explain: The system required pumping more than 4 tunes 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 explain: Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 43 Eldridge Ave. Hyannis Owner: Lew:i s 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 fail g to protect public health,safety or the environment. 1. yytem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the stem 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. Sy tem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the syste 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 s face 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 front a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: 3 Page 4 of I I ` OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM_ INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 43 Eldridge Ave. Hyannis Owner: Lewis Date of Inspection: - 'fib—o 9 D. System Failure Criteria applicable to all systems:. You ' ust indicate"yes"or"no"to each of the following for all inspections: Yes o _ 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 iquid depth in cesspool is less than 6"below invert or available volume is less than''/z day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number o times pumped _ y portion of the SAS,cesspool or privy is below high ground water elevation. y portion of cesspool or privy is wit_iin 100 feet of a surface water supply or tributary to a surface w ter supply. portion of a cesspool or privy is within a Zone I of a public well. portion of a cesspool or privy is within 50 feet of a private water supply well. portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water su ply well with no acceptable water quality analysis. [This system passes if the well water analysis, p rformed at a DEP certified laboratory,for.coliform bacteria and volatile organic compounds i dicates that the well is free from pollution from that facility and the presence of ammonia trogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria re triggered.A copy of the analysis must be attached to this form.] (Y 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. L rge Systems: To considered a large system the system must serve a facility with a design now of 10,000 gpd to 15,000 gPd- You st indicate either"yes"or"no"to each of the following: (The fo lowing criteria apply to large systems in addition to the criteria above) yes no _ the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinid waters l _ y utary ng 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 ave answered"yes"to any question in Sae * n E the system is considered a significant threat,or answered "yes" n Section D above the large system has Med.The owner or operator of arty large system considered a Sig ificant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15. 04.The system owner should contact the appropriate regional office of the Department. 4 1 Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 43 Eldridge Ave. Hyannis Owner: Lewis Date of Inspection: t — 1 6--fl � Check if the following have been done You must indicate"yes"or"no"as to each of the following: Yes o 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? 1 _ 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? ,I,/ 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? _V1_ 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: es 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)J f 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 43 Eldridge Ave. Hyannis Owner: Lewis Date of Inspection: y—-0 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design) Number of bedrooms(actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: _ Does residence have a garbage grinder(yes or nolh a Is laundry on a separate sewage system(yes or no):_ [if yes separate inspection required] Laundry system inspected(yes or no): Y/`1 Seasonal use: (yes or no):AL 0 Water meter readings,if available(last 2 years usage(gpd)): 1 9 9 9—2 0 0 0 137, 250 gal. Sump pump(yes or no);/io 2 0 0 0—2 0 01 120, 750 gal. Last date of occupancy: COM ERCIAL/INDUSTRIAL Type o establishment: Desig flow(based on 310 CMR 15.203): gpd Basis f design flow(seats/persons/sgft,etc.): Greas trap present(yes or no): Indus ial waste holding tank present(yes or no):_ Non- anitary waste discharged to the Title 5 system(yes or no): Wat r meter readings,if available: Las date of occupancy/use: O HER(describe): GENERAL INFORMATION Pumping Records Source of information: 12 c• g ';k.,CS--a- Was system pumped as part of the inspection(yes or no): If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping: JT %4- -0 TYP OF SYSTEM Septic tank,distribution box,soil absorption system _Single cesspool _Overflow cesspool Privy _Shared system(yes or no)(if yes,attach previous inspection records,if any) _Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank _Attach a copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source o information: Were sewage odors detected when arriving at the site(yes or no): //C> 6 i Page 7 of l I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 43 Eldridge Ave. Hyannis Owner: Lewis Date of Inspection: Z a-o—0 9 B ILDING SEWER(locate on site plan) De th below grade: Ma erials of construction:_cast iron _40 PVC_other(explain): Di tance from private water supply well or suction line: C mments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:z(locate on site plan) Depth below grade: 12- � Material of construction: ✓Eoncrete_metal_fiberglass polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: l/ 9 Scum thickness: 0 L Distance from top of scum to top of outlet tee or baffle: _ Distance from bottom of scum to bottom of outlet tee or baffle: 7Ct' Ap How were dimensions determined: 6 /', Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of.leakage,etc.): GR SE TRAP:_(locate on site plan) Depth below grade:_ Matey' 1 of construction:_concrete_metal_fiberglass_polyethylene_other (expla ): Dime sions: Scum hickness: Dista ce from top of scum to top of outlet tee or baffle: Dista ce from bottom of scum to bottom of outlet tee or baffle: Date f last pumping: Co ents(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as re ated to outlet invert,evidence of leakage,etc.): 7 Page 8 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 43 Eldridge Ave. Hyannis Owner: Lewi s Date of Inspection: -2o--d IGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) D th below grade: Ma erial of construction: concrete meal fiberglass_polyethylene other(explain): Dim ensions: Cap city: gallons Des gn Flow: gallons/day Alai m present(yes'or no):' Al level: Alarm in working order(yes or no): Dat of last pumping: Co ents(condition of alarm and float switches,etc.): DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:6 _ 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.): / MP CHAMBER: (locate on site plan) P mps in working order(yes or no): A arms in working order(yes or no): C mments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS _ SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 43 Eldridge Ave Hyannis Owner: Lewis , Date of Inspection: Z�U— SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) If SAS not located explain why: Type eaching 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.): + � , CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inle ac[t^ Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of 11 ` OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 43 Eldridge Ave. Hyannis Owner: Lewis Date of Inspection:Z —L o—O , 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.Lccate where public water supply enters the building. ,G IL � 1 r 10 II Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 43 Eldridge Ave. Hyannis Owner: ewi s Date of Inspection: �.2-& es 7 SITE EXAM Slope Surface water - Check cellar Shallow wells J� Estimated depth to ground water�2.0 feet Please indicate(check)all methods used to determine the high groundwater elevation: Obtained from system design plans on record-If checked,date of design plan reviewed: _Observed site(abutting property/observation hole within 150 feet of SAS) ,/Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elev t Q� C� I ° I i - 11 I TOWN IOF BARNSTABLE B 'W 356 Ordinance or Regulation WARNING NOTICE Name of Offender/Manager`"'' 7J�44JAawv-�-I.- r f .. .; Address of Offender A2a MV/MB Reg.# Village/State/Zip W600)s*CiyL QXV Business Name ysam/pm,, on a o�y 19 'S Business/ Address C..�/ 2 � P Signature�of nforcing Office Village/State/Zip q Location of Offense V3 En orcing Dept/Division Offense /US Gjjo f2 q, a . .6 0a Facts fi t/ / // IN cam,h This will serve only as a warning. At this time no Iegal actiojh has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the. Town. TOWN.I OF BARNSTABLE BAR-W 356 5 Ordinance or Regulation WARNING NOTICE v WA;,C- 2 Name of Offender/Manager`"`% ' '°r' '� � Address of Offender /.2..? "i ld X// MV/MB Reg.# Village/State/Zip �'��-�" Gf = t�: ��/ Business Name ld y am/pm, on Business Address6C Signature of Enforcing Off i er Village/State/Zip Location of Offense 7, , r� iJLo, Enforcing Dept/Division Offense /4)5 c ira A Facts / / �.( G ��1 Y' ip' (-7V This will serve only as a warning. At this time no legal actioti has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts. and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate. legal action by the Town. TOWN OF BARNSTABLE BAR-W 356 Ordinance or Regulation WARNING NOTICE L Name of Offender/Managerr4" `� Address ;of Offender ? � � l't r�l ��.- MV/MB Reg.# Village/State/Zip RUC " j Business Name A0 yS am/pm; on '4 19 '.� M Business Address r Signature of Enforcing Officer Village/State/Zip Location of Offense 4ZI171�&r I� a,/'//7 -T Enforcing Dept/Division Offense /05 Chi q1,0 • 6 Facts , ll e'S U'f 71?`4517 k Y F t� 1 °; A0 ej 4."'-a v,r This will serve only as a warning. At this time no legal actioh has been taken. It is the goal of Town agencies to achieve voluntary compliance of Town Ordinances, Rules and Regulations. Education efforts and warning notices are attempts to gain voluntary compliance. Subsequent violations will result in appropriate legal action by the Town. { ! _ Real state' Sys.{'em Genor .:t1- t («ar::?hrty ?n(::ui,ry Help. it : P aQce l 1.d: ...'-P .. 4` 3 Account No _08_.` Wt.3f'l C:N A 4 d._uc^trtikv."�: ELDRIDGE 4111E 'r-1Y(�P�4NAdi - ;I`J�i.g�bornaods �...;-�lD -€�*�:.��+ �s�r; Pove l tat 8 Lot Size: ::3 sr ,brad ti@. :llrI" ( .her � . =lWf ;L ��xin Own: Slot, closet Ink � :i Fz + rua nMing ==I {— 8 q ` fd ! 4tti^ { 9. 9es co ifl 11 +J �� ,.iIm._t= t"y :=,•i: ,C',_,tii'AN,i . F.I,JAR ,+ n Peed {'7OT10 :I. .??2 Deed tieF= SlAt16S kr'),r.lt,r 7 Q J ( t^.4's'° Lc+nC.F•"`'_ 24100 j3 )�I Bu7 ltand s 033 F r;s Features, w1VENUE 14 Yt ri 7 1 �,.;C.}f1�i�i'^(_I:{. lL1'Fah I._as i-gtp .U1'?C]i: _alt iA&S l.{1; datel 060193 - . 'I,.-:and E,,eV etJa"d Byg '` �Z..l+a1 A c3�s(;P ��1c:i(��.�• ,RbvfewC)C:l .BYE ma n al:�e• '(,� ,3 u ` Title: t�(.�i�r�a'.sn�tx..' l �1 c:sn Aci_(-it_(rit S{•_a•L-ur` o1.tJ S tia;l:,um - POPOTAKWAT Oar Amme data icl 292 Numbdr n 1 S V Commonwealth of Massachusetts ^. Executive Office of Environmental Affairs NOV �fr< Department of S Environmental Protection J�-A r :a Wllllam F.Weld Trudy Coxe t3orsrnor SwNary Argeo Paul Celluccl David B.Struhs, U.Goornor Commlrlornr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A - CERTIFICATION property Address: 43 Eldridge Ave, Hyannis Address of owner. Edward=Curran Date of Inspection: Nov. 8, 1 9 9 6 (If different) Name of Inspector. W.E. Robinson SR Company Name,Address and Telephone Number. ( 5 0 8) 7 7 5—8 7 7 6 W.E. Robinson Septic Service, P.O. Box. 1089 Centerville MA CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sew disposal systems. The system: /Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: 14 1 t� Date: The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B, C,or D: A] SYS PASSES: I have not found any information which indicates that the system violates any of the.failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. yes,no,or not determined(Y,N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal, cracked,structurally unsound, shows substantial infiltration or enfltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. (re i ed 11/03/95) 1 One Winter Street a Boston,Massachusetts 02106 • FAX(617)556-1049 • Telephone(617)292.5500 �AJ Printed on Recycled Paper c SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 43 Eldridge Ave, Hyannis Owner. Edward Curran Date of Inspection: Nov. 8, . 1996 B]SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pees inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C1 THER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health,safety and the environment. SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: — Cesspool or privy is within 50 feet of a surface water — Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. — The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. — The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. S) THER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 43 Eldridge Ave, Hyannis Owner. Edward Curran Date or Inspection: Nov. 8, 1 9 9 6 D) SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. _ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution boa above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El I.AE E SYSTEM FAILS: e following criteria apply to large systems in addition to the criteria above: system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public and safety and the environment because one or more of the following conditions exist: the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone H of a public water supply well) The owner r operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requireme t8 of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information., (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST property Address: 43 Eldridge Ave, Hyannis Owner. Edward Curran Date of Inspection: Nov. 8, 1996 Check if the f��"um ' have been done: ping information was requested of the owner,occupant,and Board of Health. _k,*"one of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. ZA,built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. W The system does not receive non-sanitary or industrial waste flow -/The site was inspected for signs of breakout. system components,excluding the Soil Absorption System,have been located on the site. 'he septic tank manholes were uncovered,opened,and the interior of the septic tank was inspected for condition of baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge, depth of scum. _ 'h,size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. .ae4e facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- surface Disposal System. (revised 11/03/95) 4 f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 43 Eldridge Ave, Hyannis Owner. Edward Curran Date of Inspection:' Nov. 8, 1 9.9 6 FLOW CONDITIONS RESIDENTIAL- Design tlow:�®gallons Number of bedrooms:j-,L/ Number of current residents: `- Garbage grinder(yes or no):�.6 Laundry connected to system(yes or no)-Lf. S Seasonal use(yes or no):_ Water meter readings, if available: 91 , 700 — Nov 1994 , 96, 000 — Nov. 1995, 114 , 700 — Nov. 1996 Last date of occupancy:6 4 COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings,if available: Last date of occupancy: OTHER(Describe) Lest date of occupancy: GENERAL INFORMATION PUMPING RECORDS and urce of information: �d System pum as part of inspection: (yes or no)," If yes,volume pumped: ¢allons Reason for pumping: TYPE OF STEM aptic tank/distri ration box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes,attach previous inspection records,if any) Other(explain) APPROXIMATE AGE of all component a,date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no)Ito G (revised 11/03/95) 5 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Address: 43 Eldridge Ave, Hyannis Owner. Edward Curran Date of Inspection: Nov. 8, 1 9 9 6 SEPTIC TAN&Z (locate on site plan) Depth below grader /co _ Material of construction _metal_FRP_at explain) i Dimensions: Sludge depth: tk— Distance from top of sludge to bottom of outlet tee or baffle: 4 j a a Scum thickness: I"3 ' ` Distance from top of scum to top of outlet tee or baffle: r Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or as,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) �o �.1'� `w d! " I a i * G TRAP:_ (locateo site plan) Depth ow grade: Mate ' of construction:_concrete_metal_FRP_other(e:plain) Dime ions: Scum Distance m top of scum to top of outlet tee or baffle: Distance m bottom of scum to bottom of outlet tee or baffle: Comments: (recomme tion for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence leakage,etc.) (revised 11/03/95) 6 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) pmp,,VAddb,,; 43 Eldridge Ave, Hyannis Owner. Edward Curran Date of Inspeotion: Nov. 8, 1996 TIG OR HOLDING TANK:_ (locate site plan) Depth grade: Material of n:_concrete_metal_FRP--other(explain) Dimensions: Capacity: ons Design flow: ons/day Alarm level: Commen (condition o et tee,condition of alarm and float switches,etc.) DISTRIBUTION sox (locate on site plan) . Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box,etc.) PUMP C HER. (locate on plan) Pumps in rking order:(yes or no) Commen (note coed, ' n of pump chamber, condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Addnmm 43 Eldridge Ave, Hyannis Owner. Edward Curran Date of Inspection: Nov. 8, 1996 SOIL ABSORPTION SYSTEM (SAS):-Vl (locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits,number: leaching chambers,number:_ leaching galleries, number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool, number: Co ts: (note condition of soil a of h draulic failure, level of G l my}en � signs ponding, condition of vegetation,etcJ � � � dC„A � �h �✓ a < �i C LS:_ (locate site plan) Number d configuration: Depth-top f liquid to inlet invert: Depth of lids layer: Depth of layer: Dimensio of cesspool: Mate , of construction: Indicati of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: ( condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation,etc.) PRIVY:_ (locate on s' plan) Materials of nstruction: Dimensions: Depth of ao Comment6: (n condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etcJ (revised 11/03/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 43 Eldridge Ave, Hyannis Owner. Edward Curran Date of Inspection Nov. 8, 1 9 9 6 SI(ETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' l � J DEPTH TO GROUNDWATER Depth to gmndwater:_L-�:4feet 1 method of determination or approximation: 6 -{ q (revised 11/03/95) 9 No--------- Fas...... ................ THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH . .................... OF......................................................................................... Appliratiun -fur Rspaoal Works Tonstrurtiun Prrntit Application is hereby`made for a Permit to Construcl or Re air ( ) an Individual Sewage Disposal o. System at 77 - 9 ---------- o Ads or Lot No. ------..... ......Xr................... Owner Address W Installer Address Type of Building Size Lot......I �-------------Sq. feet -, Dwelling—No. of Bedrooms............. .........................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( ) Otherfixtures ...................................----------------......................................................................... .. W Design Flow............................................gallons per person per day. Total daily flow.......9�_�--o------------------------gallons. WSeptic Tank—Liquid capacity/ allons 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---------------C..s(l. ft. z Other Distribution box ( ) Dosing tank ( ) ~ y _ .� Percolation Test Results Performed b __________________________________________________________________________ Date_____.___. a __7 _ Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-..--.-_.---..-.--.-_... �14 Test Pit No. 2.....:..........minutes per inch Depth of Test Pit.................... Depth to ground water--.-.---._-..-:-__-_.._. 9 -------------•---•----------••---••--••------------------•-••--------'•---------•-••-----•----'-----......................................................... ODescription of Soil--- ----------JA,�_d.-........ - R --------------------------------------------------------------------------------------------------------- U ---------------------------------------------------- �- r✓e WG a fvfa7ds8'�� --------------------------------------------------------------- x ----------------------- --------------- ---------------------------------------------------------------------------------------------------------- -------------- ------------------------------------- U Nature of Repairs or Alterations—Answer when applicable.:---------------------------------------------------------------------------------------------. ---------------------------•-----•--.-.-----------------.----_-----------------------------------••-----------------••----------••---------------------•------------------- -•-••---------------------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article NI of the State Sanitary de—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has Pd y the board health. Signed. ---------•-------------------------- -------------------------------- Date a• P 7� Date Application Approved By. L ' Date Application Disapproved for the following reasons_...._............................................ .......................•-------•-•--•-•--.. ......--•------- . •-•---••----•••---------------•-----•--.......----------.......---------•-•---•--...-- •------- - ----------- ----------------------------------- �'` L/ Date Permit No.------34--1..................................... Issued.._ Date - - -�----- - - - - ------------------------------ J t- l NO......................... Fps.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ........ ... ... .................OF............................................................ Appliratinn -fur Uhipufittl Eorko Tongtrurtinn Vrrniit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: 7 ----------- ------------- �=--.�----------------------- ------------•-------- Lot No. Owner Address W ----------------------------------------------------- ------------------------ Installer Address UType of Building Size Lot...... ---Sq. feet Dwelling—No. of Bedrooms------------ .............................Expansion Attic ( ) Garbage Grinder aOther—Type of Building ____________________________ No. of persons.--------------------------- Showers ( ) — Cafeteria ( ) dOther fixtures ---------:---------------------------------------- ------------------------_- .......................... W Design Flow______ _________g ____________________________gallons per person per day. Total daily flow.......- .= )----------------------..gallons._ WSeptic Tank—Liquid capacity/ tllons 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 "lest Pit-.._______________-_ Depth to ground water._-__--_____-____--__ (_, Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water_,--_-_-___--__-_------- a ---------------------------•------------•-•_.._._---------------••-••--•--------------•--•._.._-----......................................................... 0 Description of Soil--------- �i;-'- Z!•-•--••-- t' -----'= -•=-•--------------------------------------------------------------------------------------------------- -------- U ----------------------- -----------------••------•-------------•__.••-----•---•-------•!_.-- x ----- ------- ------------------------------------------•--•-•-----------------------•-------------------------•---------------------••-•-------------------•-•-------------- ------•----•--•---•------- U Nature of Repairs or Alterations—Answer when applicable---------------------------------------------------------------------_________________________ ----------- ----------------------------------------------------------------------------------------------- --------- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary de— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has ben ssued'by the board health. 07 Signed---- ----•-/�-�----•- E?__.~_0 _ter_^_ ---•------------••-•------:------•--•-------------- Datei ApplicationApproved By----- -•---l-L------•••-•---------------•--.._..-•••--------------------..._•------------ �� Date Application Disapproved for the following reasons:-------•---•---•---------------•---•--•-------•-•-•-----------•-•-••------------_-••-••---••-------------------- ------------------•-•--------••-•---•----•-•------------•---•....._..._..-------•-----•----- --•----------------------------------------------------------- Date PermitNo.------ -------------------------------------- Issued----------------------- ............................. Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH .......-...�:.:...�.--...............OF............./�./......:....s. ..............-.....--................ 01rdifirntr of flumVlianrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( ) by._.._.. - t/ . < rJG//i /� ---------------------------•-- ------------------------------------------------------ •-- - -------••-••--- '7` Installer at•-----•--•----------------------•----- ---'---------� ---'---------------•----------------1 has been installed in accordance with the provisions of Article XPr of The State Sanitary Code as described in the application for Disposal Works Construction Permit No------------d. _______________________ dated-...___.v_ 2<_.___n_%_________.___- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT 09, CONSTRUED AS A-GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. x� DATE Inspector--------•-•--•----_.. ----------••----••-••••-•-••- r THE COMMONWEALTH OF MASSACHUSETTS LJj r- 4 BOARD OF HEALTH ................... .......0F....... / ..1.4...r/ pl c-.....--..... -------------------------- No.._•-----•-- 1----- FEE........•...`.......... MnVo,inl Murky inn trurtiu$t rrmit Permission is hereby granted_____________ J�"�� .'-------------=�`l/--J/-=----- _________________ to Construct or Repair ( ) an Individual Sewage Disposal System atNo.- •-----•-------•--•----• ' ' f Street , as shown on the application for Disposal Works Construction Permit No-------- J___________ Dated.......!.................................` - fu ^ �/� 7.7 and of Health DATE. ............... ---- ------------------ (/ FORM 1255 -HOBBS & WARREN. INC.. PUBLISHERS t J Lo K'ouhn, TJN r tie t�/S tk/6v/i�w�7�sr-le.-4 Yv 671� t f*cc ?IT 1U J F •r J , .N :T�t , 1", C>✓QTt�I>rD p UC. -r p>t._./Str..� L OCAT►O V!J 1`�L�, t•.1� 1 N1 AS S r-SSZTtt=14 T14AT' TN1= R�UL.JC 11U> 3St-1t�nt�1.1 P1._At..! 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