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Home My WebLink About0023 FIFTH AVENUE (HYANNIS) - Health 23 E FTH AVENUE, HYANNIS 4 4 1 o TOY�3d O g iSTABLE F u e spawkcg y3L�:Ar�. �G 64 n ,S: t�' ASSESSOR'S: o°t .CYI' I1�STia 3.LMWS NAMc$PHONE NO SEMC TANK CAIrACP!'X Q I.F.AC jl1`tG;A,c-T- t , Pi0 4FBFDRCK}I�S: �tI�I.DR OR OtER PERMFFFT3A'FE. CrtiUMPL3ANCEIJA'FE:' Separs�on Drtance Between'`tbe Feet Ma�cuiumAdjUstecy Graun�waterTableto theBattom ofi.eachingFae'ef�ty Pnvate�►ater Supply Te11 and I dung Faciht�r E1 any.we us exist on site at antbsn MAW..t 0-Ieg fact) lsdge gf Wet#and and Leachit►g Faal ty(If ariy�rctTapds exist Feet wittuat 340.feet aj-.16ae pg. 4. T Fuu_s_hed by LJ QJ ;. e � w A �I 1 O � � 1 ca 9a i TOWN OF BARNSTABLE LOCATION, `� SEWAGE # VILLAGE k)o-': t�3!'T ASSESSOR'S MAP & LOT NAME&PHONE NO.N1 ,1 '6 SEPTIC TANK CAPACITY meo f LEACHING FACILITY: (type) 6 7 ' 7 (size) 1/� NO.OF BEDROOMS BUILDER OR OWNER a PERMTTDATE: � COMPLIANCE DATE: 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 fe of leachin ac' ' ) Feet Furnished hJ >r I s (� „V I � •ST/1 i � " � � \ � � �r�`�� Q - 0 !s a / i � l �+ S � ', C � � ' ,�, s ^'�� ., �1 1 4 ", Commonwealth of Massachusetts Title 5 Official Inspection Form '`A i�i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Fifth Ave Property Address 10 Charles Robbins Owner 1, Owner's Name information is H annis ort MA 02672 7-24-19w" required for every y p page. City/Town State Zip Code Date of Inspection ,1 Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. A. Inspector Information /-f0 Shawn Mcelroy Name of Inspector Upper Cape Septic Services Company Name P.O. Box 73 Company Address E. Falmouth MA 02536 City/Town State Zip Code 1-568-495-0905 S13971 Telephone Number License Number B. Certification I certify that:l am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at theproperty address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 7-24-19 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 c Commonwealth of Massachusetts r� Title 5 Official Inspection Form I Subsurface Sewage Disposal System Form -Not for Voluntary Assessments A (�a 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is required for every W. Hyannisport MA 02672 7-24-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® 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 failure. 2) System Conditionally Passes: ❑ One or more system components as described in the "ConditionalPass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑N ❑ ND (Explain below): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 f Commonwealth of Massachusetts r� ,w Title 5 Official Inspection Form i�► Subsurface Sewage Disposal System Form -Not for Voluntary Assessments U 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is Hyannisport MA 02672 7-24-19 required for every ' page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y. ON ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑N ❑ ND (Explain below): ❑ distribution box is leveled or replaced El ❑ 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 ON ❑ ND (Explain below): ❑ obstruction is removed ❑Y ON ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 Commonwealth of Massachusetts 3 Title 5 Official Inspection Form it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments . .a 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is required for every W. Hyannisport MA 02672 7-24-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑The system has a septic tank and SAS and the SAS.is within a Zone 1 of a public water supply. ❑The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or"No"to each of the following for all inspections: Yes No ❑ ® 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 t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 i Commonwealth of Massachusetts r� 3 Title 5 Official Inspection Form ,,. it Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is required for every W. Hyannisport MA 02672 7-24-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® 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 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 water supply 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 2000 gpd- 10,000 gpd. The system fails. I have determined that one or more of the above failure ❑ ® criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems:To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments t ti>`' 23 Fifth Ave ter_ Property Address Charles Robbins Owner Owner's Name information is required for every W. Hyannisport MA 02672 7-24-19 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate "yes" or"no"for each of the following for all inspections: Yes No ® ❑ 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? ❑ ❑ Wasthe facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 r Commonwealth of Massachusetts 1 fY Title 5 Official Inspection Form hi Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is required for every �W. H annisp ort MA 02672 7-24-19 page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flowbased on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 Description: Number of current residents: 1 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: 7-2019 Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form nl Subsurface Sewage Disposal System Form -Not for Voluntary Assessments > W 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is required for every W. Hyannisport MA 02672 7-24-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Owner---pumped 2017 Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Maintenance t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 c Commonwealth of Massachusetts 1� Title 5 Official Inspection Form �.1' I, Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is required for every W. Hyannisport MA 02672 7-24-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 4. 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: 1993 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 12"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. t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts r� Title 5 Official Inspection Form rE Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is required for every W. y p H annis ort MA 02672 7-24-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank (locate on site plan): Depth below grade: 6"feet Material of construction: ® 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: 6" Distance from top of sludge to bottom of outlet tee or baffle 26" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 6" Distance from bottom of scum to bottom of outlet tee or baffle 15" How were dimensions determined? Tape 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 is in good condition with baffles installed and no sign of leakage. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 f ` Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is required for every W. Hyannisport MA 02672 7-24-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank (tank must be pumped at time of i nspecti on)(locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 18 Commonwealth of Massachusetts ,w Title 5 Official Inspection Form �> iI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is required for every y p W. H annis ort MA 02672 7-24-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box (if present must be opened)(locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Good condition with water at working level and no sign of back-up from pit. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts r� ,w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is Hyannisport MA 02672 7-24-19 required for every W. page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1-1000 gal ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 s Commonwealth of Massachusetts il• Title 5 Official Inspection Form oSubsurface Sewage Disposal System Form -Not for Voluntary Assessments r 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is required for every W. y p H annis ort MA 02672 7-24-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leach pit in good condition and empty at inspection with stain line at 24" below inlet invert. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration - Depth —top of liquid to inlet invert Depth of solids layer Depth of scum;layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.): t5insp.doc•rev.7/2 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ICI Subsurface Sewage Disposal System Form -Not for Voluntary Assessments >" 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is required for every W. Hyannisport MA 02672 7-24-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form l Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is required for every W. Hyannisport MA 02672 7-24-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately o ci 23 A3 C f�. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form ibi Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ``" 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is required for every W. Hyannisport MA 02672 7-24-19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. 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: USGS and town maps show groundwater at greater than 12'. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 c Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Fifth Ave Property Address Charles Robbins Owner Owner's Name information is W. Hyannisport MA 02672 7-24-19 required for every page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this Section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Fifth Ave Property Address f-► Barbara Robbins Owner Owner's Name information is required for every Hyannis Port ✓ Ma 02646 3/17/16 z page. City/Town State Zip Code Date of Inspection co 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 Michael DiBuono use the return Name of Inspector key. DiBuono Sewer and Drain Company Name 8 Johns path Company Address S Yarmouth Ma 02664 City/Town State Zip Code 508-364-9587 S103522 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation *the Local Approving Authority 3/18/16 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ns-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 �dntdVs Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �,. 23 Fifth Ave ^N Property Address Barbara Robbins Owner Owner's Name information is required for every y Hyannis Port Ma 02646 3/17/16 pager City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system contains a 1,000 gallon septic tank a Dbox and a 6x6 Leach pit. Pit liquid level at time of inspection was 20" below invert pipe B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): r t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments N 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is Hyannis Port Ma 02646 3/17/16 required for every y page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 thins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is required for every Hyannis Port Ma 02646 3/17/16 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: *"This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® _ 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 '/2 day flow t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is required for every Hyannis Port Ma 02646 3/17/16 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributarysupply.to a surface water ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is required for every Hyannis Port Ma 02646 3/17/16 page. Cityrrown 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. ® ❑ 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)] s D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is required for every Hyannis Port Ma 02646 3/17/16 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: The system contains a 1,000 gallon septic tank a Dbox and a 6x6 Leach pit. Pit liquid level at time of inspection was 20" below invert pipe Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available (last 2 years usage(gpd)): Detail: 189 Gpd Sump pump? ❑ Yes ❑ No 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: t5ins•3/13 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 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is required for every Hyannis Port Ma 02646 3/17/16 page. Citylrown 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: None provided 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is required for every Hyannis Port Ma 02646 3/17/16 page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: app 32 years 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: feet Comments (on condition of joints, venting, evidence of leakage, etc.): System is vented through the roof Septic Tank (locate on site plan): Depth below grade: 1 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1,000 GI If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is Y required for every Hyannis Port Ma 02646 3/17/16 page. CityrFown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 3" Distance from top of scum to top of outlet tee or baffle 42" Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick How were dimensions determined? Tape Measure Comments(on pumping recommendations,-inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): No evidence of Ieaking,Tees and or baffles in place at time of inspection. 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is y _H annis Port Ma 02646 3/17/16 required for every 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.): Tees are in place and levels are normal. Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): "Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 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 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is required for every Hyannis Port Ma 02646 3/17/16 page. City/Town 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 Dbox is level and at normal liquid level 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.): No signs of carry over Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts 4 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is required for every Hyannis Port Ma 02646 3/17/16 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: 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 inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is required for every Hyannis Port Ma 02646 3/17/16 _ page. Citylrown 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.): No ponding no break out Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments µ„ 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is required for every Hyannis Port Ma 02646 3/17/16 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is required for every H annis Port Ma 02646 3/17/16 Y page. Cityfrown 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: 10+ ft 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: Property sits atop fifth ave high from the ocean. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 f 311812016 Assessing As-Built Cards TOWN OF BARNSTABLE -►w6 + LOCATION,;1_ 6'4 AV?- SEWAGE d r-9-7d VILLAGE ASSESSOR'S MAP&LOT •efSTAUM NAME&PHONE NO. _... SEPTIC TANK CAPACITY 1 LEACHING FACILITY:(type) 7 ' T (size) /,Zb NO.OF BEDROOMS BUILDER OR OWNER �yJLI PERMITDATE: % COMPLIANCE DATE: 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 fe of leachin ac'' Feet Furnished ny 0 http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=246194&seq=1 1/2 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Fifth Ave Property Address Barbara Robbins Owner Owner's Name information is required for every Hyannis Port Ma 02646 3/17/16 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ❑ Inspection Summary: A, B, C, D, or E checked ❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed ❑ System Information— Estimated depth to high groundwater ❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Town of Barnstable oFT Tom,, Regulatory Services Samstabig c Thomas F. Geiler,Director A A"nmfirpCAY Public Health Division &UM9 KASS. 'E�` Thomas McKean, Director 2007 �Ar f039. A 200 Main Street Hyannis, MA 02601 Office: 508-862-4644 Fax: 508-790-6304 January 13, 2009 Charles Robbins 19 Forest Road Foxboro, MA 02035 As of October 1, 2006 a new rental registration ordinance was put into affect 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 23 Fifth Avenue , Hyannis. Enclosed is an application. 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. This must be completed within (14) fourteen days of your receipt of this letter. 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 508-862-4646. Thank you in advance for your cooperation. Timothy B. O'Connell, R.S. Health Inspector Health Division Direct#508-862-4646 � 4 � DATE: - 5/9/96 PROPERTY ADDRESS: -23 Fifth Ave West Hyannisport Mass . 02672 On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 .- 1-1000 gallon septic tank. 2- 1 -Distribution box. 3. 1-1000 gallon leaching pit packed in stone . • ,tip\,''_ \< � Based on my Ins.nection, I certify the following conditions: 1 . This is a title five septic system. ( 78 Code ) AW tz 2. The septic system is in proper working 2 order at the present 'time . �,� 1990 3. No repairs are needed at the present time . SIGNATURE': �. Name:_J . P .Macomber —Jr... i Company:_J. P_Macomber & Son_Inc . Address:_-B.e-c-,66------ I------- Centerville LMass__02632 Phone:_--5Q8-77-9-3338------- I THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY s JOSEPH P. MACOMBER & SON, INC. Tank*-Ceupools-Leachflelds Pumped & installed Town Sewer Connection* P.O, Box 66• Centerville, MA 02632-0066 775-3338 775-6412 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of • Environmental Protection Wllllam F.Weld Trudy Cox@ Gowawr y Arpeo Paul Cellucci David B.Struhs LL Gowrrwr canmWorar e SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 23 Fifth Ave West Hyannisport,MA Address of owner.. 12 Sedalia Road DateofInspection: 5/9/96 (If different) Dorchester,Mass . 02124 Name of Inspector. Joseph P. Macomber Jr. Company Name,Address and Telephone Number. J.P.Macomber & Son INc. Box 66 Centerville,Mass . 02632 508-775-3338 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-s iteage disposal systems. The system: _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: The system Inspector s submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. It 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) SY9 TEM 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. Indicate yes`no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) ZJ The septic tank is metal,cracked,structurally unsound,shows substantial infiltration or exAltration,.or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03195) 1 One Winter Street a Boston,Massachusetts 0�108 a FAX(617)SWIG49 a Telephone(617)292.5= t l Printed.Raxkd P•txr SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oontinued) PropertyAddreaa: 23 Fifth Ave West Hyanni sport,Mass . 02672 Owner. John Coyne Date of Inspection: 5/9/96 B) SYSTEM CONDITIONALLY PASSES (continued) �j Sewage backup or breakout or huh 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 pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced Q� The system required pumping more than four times a year due to broken or obstructed pipe(a). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: _A/0 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. 1) 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 Aul 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. 4/0 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 60 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 6 ppm. 3) OTHER 4)6 (revised 11/03/95) 2 U6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (oonttnuod) PropertyAddross: 23 Fifth Ave West Hyannisport,Mass . 02672 Owner. John Coyne Date of Iaspootiow 5/9/9 6 D) SYSTEM FAILS: AID I have determined that the rystam violnt.w one or mo re of the following fillurs criteria as deluad 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 nocassary to cornet the failure.'. Backup of sewage into facility or system component due to an overloaded or clogged SA3 or ceupool. Dlscharga or ponding of affluent to the surface of the tround or surface waters due to an overloaded or clogged SAS or owpool. �Q static liquid level in the distribution box above outlet invert duo to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool li less than 6'below invert or available volume is less than V2 day flow. RaguU'd pumping more ilea 4 tunes in the last year NOT duo to clogged or obstructod pipo(s). Number of times pumpod Any portion of the Soil Absorption System, cesspool or privy ifs below they high groundwater elevation. Any portion of a cesspool or privy is within 100 foot of a surface water supply or tributary to a surface wator supply. 4h Any portion of a caupool or privy is within a Zone I of a public well. .APA Any portion of a cesspool or privy is within 60 feet of a private wator supply well. Any portion of a cesspool or privy is lass than 100 foet but groater than 60 foot from a private water supply well with uo acceptabla water quality analysis. if the well has boon analyzod to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to tho criteria above:- Ths system servos a facility with a design flow of 10,000 gpd or greater(Large system) and the system is a significant threat to public health and safety and the environment bocauso one or more of the following conditions exist: the rstem Is within 400 foot of a surface drinking water supply �Q the system is within 2W fat of a tributary to a surface d in]ong wator supply the system is located in a nitrogen u,nsitivo area (IDWruu Weilhoad Protection Aran MA)or a mappod Zone II of a public water supply well) The owner or operator of any such system sha l bring the system and facility Into Aill compllatuy with the groundwater trorltrunt program rvqulraments of 314 CMR 6.00 and 6.00. Ploa:9 consult the local regional office of the Department for further information., SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 23 Fifth Ave West Hyanni sport,Mass . 02672 Owner. John Coyne s Date of Inspection: 5/9/9 6 Check if the following have been done: ,Pumping information was requested of the owner,occupant,and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal Dow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. Z- A,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. - The system does not receive non4anitary or industrial waste Dow 4Tu site was inspected for signs of breakout. All system components,&cluding the Soil Absorption System,have been located on the site. 4/71e 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. ZThs site and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. 2The 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Addresa:23 Fifth Ave West Hyanni sport,Mass . 02672 Owner: John Coyne Date of Inspection5/9/9 6 FLOW CONDITIONS RESIDENTIAL- Deal gn flow:-I as rpev- • Number of bedrooms: Number of current residents-A4W Garbage grinder(yes or no): Laundry connected to system(yes or no):*5 Seasonal use(yes or no):AZ J Plater meter readings, if available:0 7— Last date of occupancy: � COMMERCIAL NDUSTRIAL- Type of establishment: Ad ri Design flow: u gallons/day Grease trap Present: (yes or no)AO Industrial Waste Holding Tank present: (ye s 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) Last date of occupancy: _ GENERAL INFORMATION PUMPING RECORDS,a A source rof inforuiati� system pumped as part of inspection: (yes or no)_ If yes,volume pumped: allons Reason for pumping: TYPE "F SYSTEM _� septic tank/distribution box/soil absorption system _dLC� single cesspool 10 Overflow cesspool 4/0 Privy ND shared system(yes or no) (if yes, attach previous inspection records, if any) Other(explain) - atA XI TE AG of all components, date installed(if known) and source of infor> i;� PP r✓r Sewage odors detected when arriving at the site: (yea or no) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) PropertyAddre" 23 Fifth Ave West Hyanni sport,Mass . 02672 owner. John Coyne Date of Inspeotlon: 5/9/9 6 SEPTIG TAN K:,�/D®0�/�IW� 7ZV4 e (locate on sits plan) Depth below grads: Material of oonstruction: concrete_metal_FRP—other(explain) Dimensions: w & E Sludge depth: d Distance from to sludge.to bottom of outlet tee or bafAe:-ALL— Scum thickness: / ! Distance from top of scum to top of outlet tee 0{ baffler Distance from bottom of scum to bottom of outlet tee or baf le: Comments: (recommendation for pumping,condition of inlet and outlet tees or banes,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) GREASE TRAP: _4604- (locate on site plan) Depth below grader Material of construction:Ndooncrete_metal_FRP_other(ezplain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baMe:A Distance from bottom of scum to bottom of outlet tee or bane:f� Comments: (recommendation for pumping,oondition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, e�eace of leakage,etc.) JUD Co.�:s��lT �j (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 23 Fifth Ave West Hyanni sport,Mass . 02672 Owner. John Coyne Date of Inspection:5/9/9 6 TIGHT OR HOLDING TANKAb4lt_ (locate on site plan) Depth below grade:,AM other(explain) Material of oonstructionfVLooncrets_ _metal FRP_ Dimensions: Ul0. Capacity: h4A Gallons Design flow: ons/day Alarm level:P Comments: (conditiog of inlet tee,condition of alarm and float switches,etc.) (•0 v+1 4�* DISTRIBUTION BOX: (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.) Distribution box . is level. Has e ual distribution; o evidence f so i s carry over•No evidenc f repairs are banded At n Tn.a PUMP CHAMBER:-A '. (locate on site plan) Pumps in working order:(yes or no)- Comments: (note condition of pump chamber,condition of dumps and appurtenances,etc.) _ (revised 11/03/95) 7 U SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 23 Fifth Ave West Hyanni sport,Mass . 02672 Owner. John Coyne Date of Inspection: 5/9/9 6 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible;excavation not required, but may be appradmated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number: leaching galleries, number:_ leaching trenches, number,leagth: leaching fields, number, dimensions _ overflow cesspool, number:0 Comments: (note condition of soil sigtrs of hydraulic failure, level of pondin , condition of vegetatio etc.) Medium sand to dine sand;No signs ofiydraulic fai�'lure or ponding; All vegetation is normal. No repairs needed at this time. CESSPOOLS:/SIQ (locate on site plan) Number and configuration: A Depth-top of liquid to inlet invert: Depth of solids layer: �— Depth of scum layer: y 19, Dimensions of cesspool: IV Materials of construction: ADF—_ _ Indication of groundwater: Id fi. inflow(cesspool must be pumped as part of inspection) NR' Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) NO C641tk "715j PRIVY: (locate on site plan) Materials of constrv1On: Dimensions: A4 Depth of solids:A1 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (revised 11/03/95) b SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) PropertyAddresa 23 Fifth Ave West Hyannisport,Mass . 02672 Owner. John Coyne Date of Inspection: 5/9/9 6 SKETCH OF SEWAGE DISPOSAL SYSTEM: • include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Hyannis Water Company 775-0063 n 9h l4- ' it TN ,44, DEPTH TO GROUNDWATER Depth to voundwater.,2 0 t- feet method of determination or app tion: �Installed tank Box pit 1-19-93 No water encountered at 141 . Permit 93-z� (revised 11/03/95) rl , i I i i THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE No....c�,�.' FEEA...3.2.t.0.0 Diopnsat Workii Tamitrudion prncit J P Macomber Jr. Permission is hereby granted.......................................................................---.-............................-...-.......-......................... to Const uct �)) % Repair XX ) an Individual Sewage Disposal System at No..-- -.- tt1 Ave West H, annisport ..-•--•...................................................•-----........................................................................ Street as shown on the application for Disposal Works Construction Permit No..171.2--5.. Dated.......................................... ............................... . .._._ of Health.. DATE..............�..'•.l..�--..�1..3...-...-....--•--...._...-........-. Boar.d. FORM 36508 HOBBS&WARREN,INC..PUBLISHERS THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Tertifirate of V((��omplianre THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ICXX ) by .....J..P.Macomber Jr. :.......... .... .............................................................. hsuurr at .....2. .... .th....Aye...Wes.t....Hy.an.ni-spo.rt............................................................................................................................................... has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. ........7. 3.-....v ...��.......... dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNC 1 .. .I .S TISFACTORY.. ...... Inspector ............ , ....................................................DATE ..........:. "... . ...3............................... , Lin i THE COMMONWEALTH OF MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. J Has satisfied the Department's qualifications as. required and is hereby authorized to use the title CERTIFIED TITLE 5 SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. June 8, 1995 Acting Director of the� ion of Water Pollution Control .•m.*trnt-:s:•tT�-rTa-r-rr.•nrtrT•.*S.r...T.r.:-:r.�er�r:Trr.f..•T+Trr-�-t:r-•r.-rC rT ._ ._ . .. . -. . ._.. -_•rrr..�l-.-rrr-.:.:•.:-••I Ik 'I'OHN OF Barnstable BOARD OF HEALTH SUBSURFACE SFHAGF DISPOSAL SYSTEM INNSIFCTION FORM - PART D •- CERTIFICATION '��. F..._..;_r....,.a--,s:.:-•..:mar.-n•r,:rr:--•--ar.�—�-r-••;•-:.—.-:r-r-s-.-trrssr _ .- istrr•rmm. c:s-*rrrrrrrn.—rrr r. -s. -TYPE OR PRINT CLEARLY- PROPERTY INSPECTED STREET ADDRESS 23 Fifth Ave West Hyannisporrt,Mass . 02672 ASSESSORS MAP , BLOCK AND PARCEL # k OWNER' s NAME John Coynd . — PART D - CERTIFICATION r NAME OF INSPECTOR Joseph P. Macomber Jr.. COMPANY NAME J.P.Macomber & Son INc. COMPANY ADDRESS Box 66 C .n erville ,M G�632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of ,inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one: XXXXXXXXXSysteui PASSED The inspection «hick I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have conducted has found that the system" fails to protect ,the ptibli,c health and the environment in accordance with Title 5 , 310 CMR 15 . 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature Date _ 5/17/96 One copy of this rt.ification must be provided to the OWNER, the BUYER ( where appl icable ) and the BOARD OF 11EALTII. * If the inspection FAILED, the owner or,,,o-operator shall u y P p pgrade ' the s etem within one year of the date of the inspection, unless allowed or required otherwise as provided in 310 CMR 15 . 305 . TOWN OF BARNSTABLE LOCATION )�'Y%A 46 SEWAGE # VILLAGE ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. SEPTIC TANK CAPACITY �,moo-6 a 1 LEACHING FACILITY:(type) /� T (size) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: 1. VARIANCE GRANTED: Yes No _ , `N _9'/ I � � i I 6 � % � L /f � / i I �� `i �, e Sh � ` ( J �� ems, ' . r � � s 1 �/: � �. � / �� i •� .� � i, Fxs... THE COMMONWEALTH OF MASSACHUSETTS ` BOAR® OF HEALTH APpq TOWN OF BARNSTABLE �Co OVEN r►se^�aton Doartn*,t Aplirilart for Disposal Works tr �8 i# 9 _9� Application is hereby made for a Permit to Construct ( ) or Repair F(XX) an Individual Sewage Dispo . System at: 2 th Ave West H annis r --..3...5..._........_.......... �Q - ------------------- ------------------------------------------- ----------.........--------...........--- ......... •..... ------------- John Coyne Location.Address or Lot No. Owner Address WJ.P.Macomber Jr...................................................... --•---...-•--•----------------.......------.....-------•-----••-•------------------•......---••••- Installer Address d Type of Building Size Lot............................Sq. feet U Dwelling�C No. of Bedrooms............. .............................Expansion Attic ( ) Garbage Grinder ( ) Other—Type of Building ............................ No. of persons.......-_.__.....__.._..._._ Showers Cafeteria ( ) Otherfixtures -------------------------------------------•-------------------•------------•-------•-----....---•----•------ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length..................... Total leaching area....................sq. ft. Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ W 4 Test Pit No. I................minutes per inch Depth of Test Pit...--.---........... Depth to ground water------------------------ rX. Test Pit No. 2................minutes per inch Depth of.Test Pit---_................ Depth to ground water........................ P4 ---•----•---•-•--•----------•-••--•----------------•--••-------.....----...........--•-••......•---•......................................................... 0 Description of Soil........................................................................................................................................................................ x Sand & Gravel U -----------------------•--•-----••--•-----•-•-----•--•-••-••-----••-----•----------•-----------•-••--••-------------•••-----•-•----------•--••-----•---•---------------------........_-----••---......•. W UNature of Repairs or Alterations—Answer when applicable_. ---1-1000--------------------EQallon septic tams_ 1- distribution box -1-100�_�allon_..leac_... ; pit Packed---in. stone Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Complia e has bcenp,sued by the b�and of /eah. Signed A� .�f./- �+��f Z--tG�--- ---------- ..................8 Dace Application Approved By . _ ------- ----------------------- ----�,..,,.,,''- �...---------------------------------------------------------------- ------� �-' Dace Application Disapproved for the following reasons: -..... .... ........................ -- --------------- ..................... -- ------------------ -------------- 9 ^ / Dare Permit No. ............ / 3.--....L. Issued Dare No... •-�---.�.�... Fps...$ �0,�00. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE App iration for llionooal Works Tonstrur#iun.- .e�uti# -, 4 _s2 Application is hereby made for a Permit to Construct ( ) or Repair)(XI) an Individual Sewage Disposal System at: ."\ _2 5 tl�_aA?�P-w �.t:..Her.;!.n►�is s�.r- ------------------- ...............................................- -.........................____....... John Coyne Location-Address or Lot No. :�__....._..__.... ................................................. ..........--................................. - ........... Owner Address a .. ................................................... ....•----..._...------------......---•-----------------------....---------------------............ Installer Address Type of Building Size Lot............................Sq. feet .-t Dwelling X_No. of Bedrooms.............P.............................Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures -----------------------------------------------------------•---•---•---•-•-••••-•-•---------••••-•-------------------......•----......._..__......---- W. Design Flow............................................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity........____gallons Length____.__-___--- Width................ Diameter..._....._.__._ Depth................ x Disposal Trench—No..................... Width.................... Total Length-___--_-....._-_---_ Total leaching area____...-_____-_..__.sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date---•------------------------------------ Test Pit No.' 1________________minutes per inch Depth of Test Pit.................... Depth to ground water----_-_______-__--__.__. 44 Test Pit-No. 2................minutes per inch Depth of.Test Pit---.__-------------- Depth to ground water------------------------ f . ...-- O Description of Soil..........------------------------•-------------------.._.....------------------------------------------------------------------------------•------------------------- W Sa6d & -Gravel . ` ........... w x ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ Nature of Repairs or Alterations—Answer when applicable_..._..1-10JrJ_-_gallon__septic___tan_____J,_-_______. U d stribution..box.... _-1000___ Tallon__leach na___pit__Pack_ed_-_in_ st onP_______________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliatl�e has been/sued by the bo� d of heaall h. Signed . -..�/'t /�--- /e�'- !!-1.• pp 1/l /9 Dare APPlicat Qn Approved By -- - .0 �. �---- �--�.,,, �,"""-;---- f. ...1--�T--= C�-----�, Application Disapproved for the following reasons: ----------------------------------------------------------------------------------------------------------------------- q ................. V No. --------., -?---- �- I - Issued ate...... i Dale THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE (fer#tfiratr of Tontyliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired(CXX ) by J.P.Macomber Jr Installer at ---23...5t.h-- Ave.--Wes-t--Hyannsport----------------------------------------------------------- --------------------------------------------------------------------------------- --- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal Works Construction Permit No. .........'73 --.- ---T-------- dated ------------------------------------------------ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE----- - -� " ;' Inspector ------------ - :: . THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH q TOWN OF BARNSTABLE No...../. FEEII. K s 00_ Raposal Works Tunutrudion rrm' ff J.P.Macomber .Jr. Permissionis hereby granted-------•-• -•---••--------•-•----------------------•-----•-•----------------••••-----•----••---------...•---._..............---- to Construct ( ) or Repair)(X ) an Individual Sewage Disposal System at No....23-_-5th Ave West H.fannisport - -------------------•------------------------------------------------------------------- Street q as shown on the application for Disposal Works Construction Permit No._1�._ :�A_ Dated.......................................... DATE...............`I-..--(5-' --- --•................................ Board of Health ---. FORM 36508 HOBBS&WARREN.INC..PUBLISHERS