HomeMy WebLinkAbout0230 FAWCETT LANE - Health 230 Fawcett Lane
Hyannis p`
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TOWN OF BARNSTABLE
LOCA11011q Wce �L�n SEWAGE #
VILLAGE 4d `.5 ASSESSOR'S MAP&LOT
INSTALI-ER'S NAME&PHONE-NO.
SE,P71C TANK CAI ACITY /6-6ro
LEACfUNG FACE.s'TY:( ) Z eA (size) X 1400 6, 1
NO.OF BEI�f�Gf3,AS
BUILDER OR GWNF-I<
PER °ELATE: COMPLLANCE DATE:
Sepamtion Dista=Between the:
Maximum Adjusteed Groundwater Table to the Bottom of Leaching Facili ty Ezell
Private Water Supply Well and Lea ngg Facility f any wcus eat
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching l:Ncility(if any wetlands e.ist
with-in 3Q{}feet Q leacltin �Ji I~eetPurrtighed 0 v!- i G� 2` C.K e ' � ____.__w t
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TOWN OF BARNSTABLE
LOCATION 30 SEWAGE #
VII LADE ASSESSOR'S MAP & LOT 1
INSTALLER'S NAME&PHONE NO. ��}}
SEPTIC TANK CAPACITY 1 OQ O Q
LEACHING FACILITY: (type) Len 0,,hla : (size) ` o
NO. OF BEDROOMS
BUILDER OR OWNER
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the: I 1�e on
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by J &(1.1 cA
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Commonwealth of Massachusetts G10
W Title 5 Official Inspection Form Z�"
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
230 Fawcett Ln
Property Address 2
OCWEN 7� — J
Owner Owner's Name
information is required for Hyannis MA 02664 5-20-08
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.
A. General Information
1. Inspector:
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
29 Atwater Dr
Company Address
E. Falmouth MA 02536
City/Town State Zip Code
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
C=
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
C� Title 5 (310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
5-20-08
4 Inspector's Signature Date
1
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.
1
t5insp-03/08 - - _. - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 15
l
T
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
230 Fawcett Ln
Property Address
OCWEN
Owner Owner's Name
information is required for Hyannis MA 02664 5-20-08
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:
® 1 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:
System is in good working order with no sign of back up. Recommend pumping now and every year
for maintenance.
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 approvediby
the Board of Health,will pass. I
Answer yes, no or not determined (Y, N, ND) in the ❑ for the following statements. If"not Ll F
determined,"please explain.
l
❑ The septic tank is metal and over 20 years old"or the septic tank(whether metal or not)isdcat
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is immineSystem will pass inspection if the existing tank is replaced with a complying septic tank asapproved by the Board of Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and ifa'Cer
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
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 230 Fawcett Ln
Property Address
OCWEN
Owner Owner's Name
information is required for Hyannis NIA 02664 5-20-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ distribution box is leveled or replaced
ND Explain:
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced
❑ obstruction is removed
ND Explain:
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
❑ , The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply Well. -
t5insp•03/08 ,., _ Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Page 3 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
;M 230 Fawcett Ln
Property Address
OCWEN
Owner Owner's Name
information is required for Hyannis MA 02664 5-20-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
C) Further Evaluation is Required by the Board of Health (cont.):
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑. ® Static liquid level in the distribution box above outlet invert due to an overloaded
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 poiion of the SAS,cesspool or privy is below high ground water elevation.
El ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
t5insp•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 230 Fawcett Ln
Property Address
OCWEN
Owner Owner's Name
information is required for Hyannis MA 02664 5-20-08
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
D) System Failure Criteria Applicable to All Systems (cont.): t
Yes No
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either`yes" or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection
❑.< ' Area-IWPA) or a mapped Zone II of a public water supply well
If you have:answered "yes"'to-any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has.failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 15
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 230 Fawcett Ln
Property Address
OCWEN
Owner Owner's Name
information is required for Hyannis MA 02664 5-20-08
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
El ®" Pumping information was provided by the owner, occupant, or Board of Health
❑ -E 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?
❑w ® 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?
E ❑ Were all system,components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
®, ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption,System (SAS) on the site has
been determined based on:
® ❑:. Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field(if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CM 15.302(5)]
. r
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 230 Fawcett Ln
Property Address
OCWEN
Owner Owner's Name
information is required for Hyannis MA 02664 5-20-08
every page. City/Town State Zip Code Date of Inspection
D. System Information
Residential Flow Conditions: ,
Number of bedrooms (design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x #of bedrooms): 330
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump? ❑ Yes ® No
Last date of occupancy: 4-08
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):
t5insp•03/08 r Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 15.
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
230 Fawcett Ln
Property Address
OCWEN
Owner Owner's Name
information is required for Hyannis MA 02664 5-20-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
General Information
Pumping Records:
Source of information:
N/A
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):
Approximate age of all components, date installed (if known) and source of information:
1980
Were sewage odors detected when arriving at the site? ❑ Yes ® No
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 230 Fawcett Ln
Property Address
OCWEN
Owner Owner's Name
information is required for Hyannis MA 02664 5-20-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Building Sewer(locate on site plan):
Depth below grade: 42
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.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 36"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: 1000 Gal
Sludge depth:
12"
Distance from top of sludge to bottom of outlet tee or baffle 20"
5"Scum thickness
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 13"
How were dimensions determined? Tape
t5insp-03108 Tide 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
230 Fawcett Ln
Property Address
OCWEN
Owner Owner's Name
information is required for Hyannis MA 02664 5-20-08
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.):
Tank in good condition with baffles in place. Recommend pumping every year for maintenance.
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):
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 16
Commonwealth of Massachusetts
L W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
230 Fawcett Ln
Property Address
OCWEN
Owner Owner's Name
information is required for Hyannis MA 02664 5-20-08
every page. City/Town 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 N/A
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.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes° ❑ 'No
Alarms in working_order: ❑ Yes ❑ No
t5insp 03/08 �,, +� - Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 15 .
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
230 Fawcett Ln
Property Address
OCWEN
Owner Owner's Name
information is required for Hyannis MA 02664 5-20-08
every page. City/Town 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:
2
❑ 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.):
Both leach pits in good structural condition. First pit showed signs of being filled to the outlet invert,
and second pit had 30"of free space above stain lines.
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 230 Fawcett Ln.
Property Address
OCWEN
Owner Owner's Name
information is required for Hyannis MA 02664 5-20-08
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Cesspools (cesspool must be pumped as part of inspection)(Locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
A -
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.):
t5insp-03/08. Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 15
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°w 230 Fawcett Ln
Property Address
OCWEN
Owner Owner's Name
information is required for Hyannis MA 02664 5-20-08
every page. City/Town 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 supply enters the building.
Alf- 3r,9 .4,0-06, -,9,
.�
t5insp-03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
230 Fawcett Ln
Property Address
OCWEN
Owner Owner's Name
information is required for Hyannis MA 02664 5-20-08
every 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: 12'
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:
Town maps show no water at 15'.
t5insp•03/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 15
i
Town of]Barnstable
�FtHE Tp�
Regulatory Services
s anx�,srAs . ; Thomas F. Geiler, Director
A,F1639. Public Health Division
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.
QASEPTIC\Disclaimer Private Septic Inspections.DOC
Town of Barnstable
ppSHF Tp� Regulatory Services Department
y�P pr
BARNSrABLE, ` Public Health Division
200 Main Street, Hyannis MA 02601
prFD MAC A.
Office: 508-862-4644
FAX: 508-790-6304 Thomas A.McKean,CHO
s
October 16, 2007 r
Maria Peralta
210 Compass Circle
Hyannis, MA 02601
As of October 1 2006 a new rental registration ordinance was put into affect
g
requiring all property owners of rental units to register their rental units with the Town of
Barnstable Health Division. According to our records, you own the rental property at 230
Fawcett Lane.
Enclosed is an application and a copy of the ordinance. Please use a separate
application for each rental unit you own. Should you need more applications, they are
available online at www.town.barnstable.ma.us. Go to the Health Division page by
looking in the Department Menu. There is a link to the Rental Registration information
on the Health Division page. You may print out as many as you need, and return them to
the Health Division with the appropriate 2008 fees included.
Failure to comply with this ordinance will result in the issuance of a non-criminal
ticket citation in the amount of$100. Each day of non-compliance is considered a
separate offense.
Should you have any questions, please feel free to call 508-862-4644. Thank you
in advance for your cooperation.
Sincerely,
-Caitie Barrett
Health Division Assistant
-Thomas McKean
Health Director
CERTIFIED MAIL# 7006 0810 0000 3525 0885
I
y
Barrett, Caitlin
From: Stanton, David
Sent: Tuesday, October 16, 2007 2:56 PM
To: Barrett, Caitlin
Subject: rental
Good afternoon Caitie,
I came across another"for rent"sign posted on a house. I don't think it is registered. #230 Fawcett Lane, Hyannis.
If you could please send them an order to register.
Thanks,
Dave
O�
Vr��,
-0 D
1
COMMONWEALTH OF MASSACHUSET'T:
EXECUTIVE OFFICE OF ENVIRONMENTAL 2WFAIRS
DEPARTMENT OF ENVIRONMENTAL PROT EIdED
n �
MAR 0 4 2002
eW
TOWHEOALTH BLE
DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR O VOLUNTARY
Y ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL
RM
PART A
CERTIFICATION
Property Address: 230 FAUCETT,LN HYANNIS,MA 02601 V 32
Owner's Name: MR HAMPE
PAM
Owner's Address: 230 FAUCETT LN HYANNIS, MA 02601 LOT
Date of Inspection: 2/12/02 s'`
Name of Inspector: (please print) i , JOHN GRACI
Company Name:
SEPTIC INSPECTIONS i
Mailing Address: 'Pt04 BOX 2119 TEATICKET,MA.02536
Telephone Number: 508-564-6813 FAX 508-564-7270
i
CERTIFICATION STATEMENT
I certify that 1 have personally inspected the sewage dpo The inspection was perforl system at this address med based onrmyttrraining and below�s
true,accurate and complete as of the time of the inspectionroved system
experience in the proper function an maintenance Title 5(310 CMRsewage isposa The l stenems. I am a DEP approved
inspector pursuant to Section 15.340
X Passes
_ Conditionally P ses
_ Needs Furth aluation by the Local Approving Authority
Fails
_ �Inspector's Signature: Date: 2/12/02i
The system inspector shall submit copy,of this inspection report 1horr hasra design flow of ty(Board of Heal
of 10 000 gpd orreater,the
�h or DEP)within
30 days of completing this inspection. If t:ie system is a shared system
submit the report to the appropriate
the a'ppro o ntg authoice of lr'rt DEP.The original should be
inspector and the system owner shall
sent to the system owner and copies,sent to the buyer, if applicable,
Notes and Comments
MEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM PASSES TITLE V INSPECTION. RECOM .
SYSTEM'S USEFUL LIFE.
****This report only describes cond'itians at the time of inspection tire
under the conditions of use ul 16u1 tiwe.'Phis
inspection does not address how the system will perform in the future under the same or differeul cundilions of use.
I'�flP 5 Imnartinn rnrm
Page 2 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 230 FAUCETT LN HYANNIS, MA 02601
Owner: MR HAMPE
Date of Inspection: 2/12/02 +,
Inspection Summary: Check A•,B;C,D or E/ALWAYS complete all of Section D
A. System Passes:
X 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: <<
SYSTEM PASSES TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
B. System Conditionally Passes:
I
_ One or more system components as described in the"Conditional Pass"section;geed 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.
n/a 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: n/a
n/a 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):
_ brokep.oipe(s)are replaced
_ obstruction is removed
_ distribu,ti-on box is leveled or replaced
ND explain: n/a
n/a The system required pumping more than 4 times a year due to broken or obstructed pipe.(s). The system will pass
inspection if(with approval of the Board of Health):
_broken pipe(s)are replaced
_obstruction is removed
ND explain: n/a
Page 3 of I I
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Evi i 2
Property Address: 230 FAUCrETT'lJN HYANNIS, MA 02601
Owner: MR HAMPE
Date of Inspection: 2/12/02
C. Further Evaluation is Required by the Board of Health:
_ Conditions exist which require furtlier.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
t
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 septicttank`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 I 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 n/a
"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:
n/a �4
- - 01+.
Page 4 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE'%SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 230 FAUCETT LN HYANNIS,MA 02601
Owner: MR HAMPE
Date of Inspection: 2/12/02
D. System Failure Criteria applicable to all systems:
You mna indicate"yes"or"no"to each of the following for all-inspections:
Yes No
X Backup of sewage into•facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool '
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped n/a.
_ X Any portion of the SAS';'cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool oV privy is within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of a cesspool:oriprivy is within a Zone I of a public well.
X Any portion of a cesspool oryprivy is within 50 feet of a private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysis. (This system passes if the well water analysis,performed at a DEP
certified laboratory,for conform 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.)
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems:
To be considered a large system the'system must serve a facility with a design now of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no ,.t9 each of the following:
(The following criteria apply to large systems,in.addition to the criteria above)
o, yi1
yes no
X the system is within 400 feet of a surface drinking water supply
X the system is within 200 feet,ofa tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—1 WPA)or a mapped
Zone 11 of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered
"yes in Section D above the.large system has failed. 'fie owner or operator of any large system considered a siguif It tWt 1111-ca(
under,Section E or failed under Section D shall upgrade the sy,slent in accol-hulrr will) 110 CmlI 15.101 'I'llo NYC I 'lll mvilcl'
should contact the appropriate regional oil-ice of the Department
Page 5 of I I
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 230 FAUCETT LN HYANNIS, MA 02601
Owner: MR HAMPE
Date of Inspection: 2/12/02
Check if the following have been done;$You must indicate "yes" or"no" as to each of the following:
Yes No ,
X _ Pumping information was provided by the owner,occupant,or Board of Health
_ X Were any of the system components pumped out in the previous two weeks`?
X _ Has the system received nonnai-flows in the previous two week period ?
X Have large volumes of water been introduced to the system recently or as part of this inspection?
X Were as built plans of the system obtained and examined?(if they were not available note as N/A)
X _ Was the facility or dwelling inspected for signs of sewage back up?
X _ Was the site inspected for signs of break out?
X _ Were all system components,excluding the SAS, located on site.'?
X _ 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?
X _ Was the facility owner(and.occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems`?:,'
r•
The size and location of the Soil'Absorption System(SAS)on the site has been determined based on:
Yes no
X _ Existing information. For example, a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CM 15.302(3)(b)]
c
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE,SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 230 FAUCETT LN HYANNIS,MA 02601
Owner: MR HAMPE ' 'xa
Date of Inspection: 2/12/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
Number of current residents: 2
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no): NO
Seasonal use: (yes or no): NO
Water meter readings, if available(last 2 years usage(gpd)):.w48
Sump pump(yes or no): NO 2661- 69jZ00
Last date of occupancy: n/a -'{ 2060 -5q�L400
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a
Design flow(based on 310 CMR(I5,203): n/agpd
Basis of design flow(seats/persons/,sgft,,etc.): n/a `
Grease trap present(yes or no): NO
Industrial waste holding tank present(yes or no): NO
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
Water meter readings, if available n/at'`'
Last date of occupancy/use: n/a
OTHER(describe): n/a
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of-the inspection(yes or no): NO
If yes, volume pumped: n/agallons- How was quantity pumped determined? n/a
Reason for pumping: n/a
TYPE OF SYSTEM
X Septic tank,distribution box, soil absorption system
_Single cesspool
_Overflow cesspool 3
_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): n/a
i'p.
Approximate age of all components,date installed(if known)and source of information:
30 YEARS, NEW PIT IS APPROX. 10 YEARS OLD BY OWNER
Were sewage odors'detected when arriving at the site(yes or no): NO
Page 7 of 1 I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 230 FAUCETT LN HYANNIS, MA 02601
Owner: MR HAMPE
Date of Inspection: 2/12/02
BUILDING SEWER(locate on site plan)
Depth below grade: 9"
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply,well,or suction line: n/a
Comments(on condition of joints, venting,evidence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site,pla'n)
Depth below grade:3"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age coh ii med by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000G L 8' 6" H 5' 7" W;.4"10""
Sludge depth: 3" <,
Distance from top of sludge to bottom ofrputlet tee or baffle:31"
Scum thickness: 3"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottom of outlet tee or baffle: 15"
How were dimensions determined: MEASURED
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a '
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a l
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommendations,.inlet and outlet tee or baffle condition, structural integrity, liquid levels as related
to outlet invert,evidence of leakage,etc.
n/a
Page 8 of 1 I
i"•
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 230 FAUCETT LN HYANNIS,MA 02601
Owner: MR HAMPE
Date of Inspection: 2/12/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working order(yes or no): NO
Date of last pumping: n/a
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX:_(if'prpsefnt must be opened)(locate on site plan)
Depth of liquid level above outlet inverty:.n/a
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.):
n/a
PUMP CHAMBER:_(locate on site'plan)
Pumps in working order(yes or no):NO
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.):
n/a
Page 9 of 1 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 230 FAUCETT LN HYANNIS,MA 02601
Owner: MR HAMPE
Date of Inspection: 2/12/02
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a ,;:
Type
1000 GAL 6' X 6' t; `, leaching pits, number: 2
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a ri leaching trenches, number, length: n/a
n/a s leaching fields, number: n/a
n/a ;'-_ overflow cesspool, number: n/a
n/a innovative/alternative system
Type/name of technology: n/a
i
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH PITS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.NEW PIT HAS NEVER HAD
MORE THAN 1' OF LIQUID IN IT. BOTTOM OF NEW PIT IS AT 10'.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a
Indication of groundwater inflow(yes or no): NO
Comments(note condition of soil,signs of hydraulic failure,, evel of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation;etc.):
P.
g: ,
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
"SYSTEM INFORMATION(continued)
f
Property Address: 230 FAUCETT LN HYANNIS,MA 02601
Owner: MR HAMPE
Date of Inspection: 2/12102
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal''system including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
i+
1 A
66
be 31
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-
" Page I I of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 230 FAUCETT LN HYANNIS,MA 02601
Owner: MR HAMPE
Date of Inspection: 2/12/02
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water,1.2.,+feet
Please indicate(check)all methods used to determine the high ground water elevation.:
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
YES Observed site(abutting`pro'perty/observation hole within 150 feet of SAS)
NO Checked with local Board,of Health-explain: n/a
NO Checked with local excavatd.'rs, installers-(attach documentation)
NO Accessed USGS database-explain`. n/a
You must describe how you established the high ground water elevation:
HAND AUGER- 12+FT.
laa
r`. 4.
_ a
L07CATION SEWAGE PERMIT NO.
'Z3® fl3 -1Oy10
VILLAGE
N T LLER'S NAME 6 ADDRESS
'dull ER 0 WN
DATE PERMIT ISSUED
DATE COMPLIANCE ISSUED
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No................ ................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
.............OF.......4 W
Appliration for Disposal Works Tonstrurtion "truth
V
Application is hereby made for a Permit to Construct or Repair (A#*r an Individual Sewage Disposal
System at: :e
,0 deywo,0
........... ---------------------------------------------------------------------------------------------
o.c.at -AAd ss or Lot No.
. .•
..... ..................................... .................................................................................................
e Address
......... ..................................................................................................
Installer Address
Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic Garbage Grinder ( )
P4 Other—Type of Building ............................. No. of persons............................ Showers Cafeteria ( )
PL4
Other fixtures .....................................................................................................................................................
Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
9 Septic Tank—Liquid capacity.............gallons Length................ Width____............ Diameter...__....._..... Depth................
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. I................minutes per inch Depth of Test Pit.................... Depth to ground water-._-_._______-____--__-.
f� Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_-__._..........._.._...
Pr' '5.......... ................... ...6 ...................................................................................................
0 --- 40
Description of Soil...... ...................................................................................................
U .......................................................................................................................................................................................................
W
Z ............................................................................................................................�_d-----------0------------------------------------------------------
U Nature of Repairs or Alterations—Answer when applicable--------- ------/I .........................................................
...................................................................................................................................................................:....................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE LE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the oard of health
---••-••--•.....-•••--•----•••••-••--••--•
........... //fn'/7�d.—Z..
Date
SiS1
ApplicationApproved By................... ...... .................................................................... ......
Application Disapproved for the fo 'owlireasons:............................................................................................Date...............
...............................................................................................................................................................................................I.........
Date
PermitNo......................................................... - Issued.......................................................
Date
FEB...........................
THE COMMONWEALTH OF MASSACHUSETTS
O BOARD OF HEALTH
- OF..................°'..�--- /.............. '.`
App iratilaat for Bhipaaa al Warks ( ontitrurtuatt pamit
Application is hereby made for a Permit to Construct ( ) or Repair (- ') an Individual Sewage Disposal
System at:
................__......_ .:........... ............................................. -•-•...--•-----............__............-----•-------•-•....•••-••-•-••--•-----.............-•---
Loeation-Address or Lot No.
-•I--•--- ----•---�.-------OJ-wner� •••••-----------•------•-••••--•---••--••- .............................................Addre.ss...........................................
re
a :.:.............. :.__..._... ........
Installer Address
U Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons...........................y Showers ( ) — Cafeteria ( )
Q' Other fixtures __________________________________
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
04 W Septic Tank—Liquid capacity............gallons Length________________ Width................ Diameter---------------- Depth................
x Disposal Trench—No_____________________ Width.................... Total Length.................... Total leaching area....................sq. ft.
` Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
~' Percolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water-.----.....-----__-_-..-
Li, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a --••------•---------•-•--•...--------••-----•-•..............•-.....----------...---••-•------...--------------.._.__.......---._....__........_...-•-------
ODescription of Soil..........................................................................................................................................................................
x
U -••-----•-•-•---•------------••-•--•-•......•------••-----------•--•-•-----------------•---------------...•-•----------------••------•••----•••------•----•---------••-------------------•-•----•••-•---
W -•--••-••----------------•-------------••---•-•-------••-•------••--------•----••-••-•----------------•----••-•••-•-•------------•-•----•-•-------•------------------•-------------------------------•--
UNature 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 TITIL- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
_
Sign -------•--=-•---------------------
.
Date.
ApplicationApproved By.................- --'�------•---------------------•---------...-------------••--•---__•--•- � ' /r"�Dd --__-•---
a
Application Disapproved for the f flow' g reasons----------------------------------------------------------------------------------------------=----•------._..._
--------------------------------------------------------------•-•---------•-----------......-----•-•-----•----•---••--••--•--•-•----------•-•---------••-----•--•----•••--------•--•-----••-------------
Date
PermitNo..........................-------- ---•----------------- Issued_'_-----------.----------------------................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.................................... ................. ..............----
Trrtifirtttj� of TaampliFattrr
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructeg (;�) or Repaired ( )
by--•--•--•-•---------------•-------...........:................_'•-----•-------•-•-•••=--------•-•---------------...--------------------------...........••-----------------
.....................
Installer
has been installed in accordance with the provisions of TI�117
�"TLhe State Sanitary Cod as Ibed in the
---------------------
application for Disposal Works Construction Permit No.__ _`" ________________________ dated--f!_--f 'r----- ........................
THE ISSUANCE OF THIS CERTIFICATE SHALT. NOT BE CONST ® AS A GUARANTEE THAT THE
SYSTEM WILL�UtTION SATISFACTORY.
DATE.. -...11. . Inspector_._.;.- ;.:...
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
lD�d '....`. .....OF.................'.:`.f . '•r
No......................... FEE........................
Biop oral Works Taatm#rudivtt panfit
Permissionis hereby granted---------+.................................................... -----.•--•_:..-------••-•-•-•--••-•---•--------•----......_.....-•-•••-•••-•-
to Construct ( ) or Repair ( )Ian Individual Sewage Disposal System
atNo - '----------------------------------•-•--.-•-------------•--•--------------.•--••----...-----••-•-•---•--•-•-----•--•--•---......._••-•--
Street
as shown on the a plicat'on for Disposal Works Construction Permit- Dated............................ �._._....
............... -------- -••-•-----••-•---------•----•---•---•-----------------------------------------
f Board of Health
DATE--f--f•. ! ----•..............•--•-W�..__-•---------------
FORM 1255 HOBBS & WARREN, INC., PUBLISHERS