HomeMy WebLinkAbout0031 FIFTH AVENUE (HYANNIS) - Health 1 Fifth Avenue
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r 07 2016 21:34 Jim The Inspector Man 5085349919 page 1
Commonwealth of Massachusetts
Title 5 Official Inspection Form =>
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
N
31 Fifth Ave tom:
Property Address C7
Karen Gistrelis R
Owner Owner's Name
information is West H annis ort MA 02672 4-7-16 x.
required For every y p
page. City[Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important When ng A. General Information 22 ,,,11fr„
on l the compout uter, �� # ��S�J ;``�p�I``�TH OF M,yS,Sq
use only the tab 1. Inspector: ��� • •'•�s�
key to move your g:' JAMES •'�'
cursor-do not James D.Sears = :�+
use
s key.
the return Name of Inspector ;
y
Capewide Enterprises LLC
Company Name 1`�l"
153 Commercial Street ���Urp11 IIINSPp0;
Company Address
Mashpee MA 02649
CityfTown State Zip Code
508-477-8877 S 1623
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that.the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
4-7-16
spector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time. This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Apr 07 2016 21:34 Jim The Inspector Man 5085349919 page 2
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments -
31 Fifth Ave
Property Address
Karen Giatrelis
Owner Owner's Name
information is required for every West Hyannisport MA 02672 4-7-16
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E I 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 15.3D4 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system is a 1000 Gal Tank D Box and pit.
B) System Conditionally Passes:
❑ One or more system components as described in the ''Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not
determined,"please explain..
The septic tank is metal and over 20 years old' or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
`A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 17
Apr 07 2016 21:34 Jim The Inspector Man 5085349919 page 3
Commonwealth of Massachusetts
Title 5 ,Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments '
" 31 Fifth Ave
Property Address
Karen Giatrelis
Owner Owner's Name
information is required for every West Hyannisport MA 02612 4-7-16 .
page. CityfTown 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
15ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 3 of 17
Apr 07 2016 21:34 Jim The Inspector Man 5085349919 page 4
• Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,. 31 Fifth Ave
Property Address
Karen Giatrelis
Owner Owner's Name
information is West H annis
required for every ort MA 02672 4-7-16 y p
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 is less than 6" below invert or available volume is less
than 1/day flow Pe T
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Apr 07 2016 21:34 Jim The Inspector Man 5085349919 page 5
Commonwealth of Massachusetts
Title 5 Official Inspection Form
R Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
w 31 Fifth Ave
Property Address
Karen Giatrelis
Owner Owner's Name
information is required for every West Hyannisport MA 02672 4-7-16
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped: '
El ® Any portion 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.
❑ ® 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.
a
❑ ® 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-
10,000g pd.
❑ ® 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
i 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.
15ins•3113 Tills 5 Official Inspection Form:Subsurface Sage Disposal System•Page 5 of 17
Apr 07 2016 21:34 Jim The Inspector Man 5085349919 page 6
Commonwealth of Massachusetts
OEM
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Fifth Ave
Property Address
Karen Giatrelis
Owner Owner's Name
information is
required for every West Hyannisport MA 02672 4-7-15
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 NIA)
® ❑ 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 CM 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 2 Number of bedrooms (actual). - 2
DESIGN flow based on 310 C M R 15.203 (for example: 110 gpd x#of bedrooms): 220
e .
t51ns•3113 Title 5 Official Inspection Form:Subsurface Sewage Ois p osal System•Page 6 of 17
P 9. P Y 9
Apr 07 2016 21:34 Jim The Inspector Man 5085349919 page 7
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
y 31 Fifth Ave
Property Address
Karen Giatrelis
Owner Owner's Name
information is West Hyannisport MA 02672 4-7-16
required for every —
page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
The system is a 1000 Gal.Tank D Box and pit.
Number of current residents: 0
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 ears usage d 2 015-8 5 Gal's
g ( y g (gP ))� 2015-8250 Gal's
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: NADate
Commercialiindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(9Pd)
Basis of design Flow (seats/personslsq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Tide 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5in5•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Apr 07 2016 21:34 Jim The Inspector Man 5085349919 page 8
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Fifth Ave
Property Address
Karen Giatrelis
Owner Owner's Name
information is required for every West Hyannisport MA 02672 4-7-16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: NA
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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Apr 07 2016 21:35 Jim The Inspector Man 5085349919 page 9
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Fifth Ave
Property Address
Karen Giatrelis
Owner Owner's Name
information is
required for every west Hyannisport MA 02672 4-7-16
page. City(Town State Zip Code Date of Irspection
D. System Information (cunt_)
Approximate age of all components, date installed (if known) and source of information:
1991 Permit # 91 - 112.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 27
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.):
' Pipeing is 4" PVC SCH 40.
Septic Tank (locate on,site plan):
Depth below grade: 17"
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: 1000Gal. Precast H-10
Sludge depth:
1
t5ins•W 3 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Apr 07 2016 21:35 Jim The Inspector Man 5085349919 page 10
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
rf 31 Fifth Ave
Property Address
Karen Giatrelis
Owner Owner's Name
information is
required for every West Hyannisport MA 02672 4-7-16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cunt,)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
0"
Distance from top of scum to top of outlet tee or baffle
12"
Distance from bottom of scum to bottom of outlet tee or baffle
18"
Asbuilt-Tape
How were dimensions determined? Sludge Judge
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 at working level. Tank and covers at 17" below grade. In and outlet baffle's. No sign of
leakage or over loading.
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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17
Apr 07 2016 21:35 Jim The Inspector Man 5085349919 page 11
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Fifth Ave
Properly Address
Karen Giatrelis
Owner Owner's Name
information is west Hyannisport MA 02672 4-7-16
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.):
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•3113. Title 5 Official Inspection Fort:Subsurface Sewage Disposal System•Page 11 of 17
Apr 07 2016 21:35 Jim The Inspector Man 5085349919 page 12
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
rks
31 Fifth Ave
Property Address
Karen Giatrelis
Owner Owner's Name
information-df y pn is West H annis ort MA .02672 4-7-16
required for every
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 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.):
D Box is 12"x 16"-27" below grade. Box is clean and solid w/one line out. No sign of over loading
or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No'
Alarms in working order: ❑ Yes ❑ Noy`
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•3N 3 - Title 5 Otfiaal Nspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Apr 07 2016 21:35. Jim The Inspector Man 5085349919 page 13
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Fifth Ave
Property Address
Karen Giatrelis
Owner Owner's Name
information is
required for every West Hyannisport MA 02672 4-7-16
page. Citylrown , 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.):
Leaching is a 1000 Gal. Precast pit. w/2'stone. Pit and covet at 2'. Pit is dry w/stain line at 18" off
bottom. Wall's are clean, like new. No sign of over loading or solid carry over.
I
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•3113 Title 5 Official Inspection Form:Subsuface Sewage.Disposal System•Page 13 of 17
Apr 07 2016 21:35 Jim The Inspector Man 5085349919 page 14
Commonwealth of Massachusetts
r Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Fifth Ave
Property Address
Karen Giatrelis
Owner Owner's Name
information is required for every West Hyannisport MA 02672 4-7-16
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, �.
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
y t5ins•3f13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
A
Apr 07 2016 21:35 Jim The Inspector Man 5085349919 page 15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
P Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
31 Fifth Ave i
Property Address
Karen Giatrelis
Owner . Owner's Name
informationis
required for every West H annis o rt MA 02672 4-7-16
page. City(rown 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
13 x�
/3-_6�
R EPP A
7 •v
c °
v
t5ins-3113 Title 5 official Inspection Form:Subsurface Sewage Disposal System Page 15 of 17
Apr 07 2016 21:36 Jim The Inspector Man 5085349919 page 16
Commonwealth of Massachusetts
= Title 5 Official Inspection Form
Subsurface Sewage Disposal System form-Not for Voluntary Assessments
a
31 Fifth Ave t
Property Address
Karen Giatrelis
Owner Owner's Name {
Information is ort MA 02672 4-7-16 West Hyannis
required for every p
page. CityfTown Slate Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
t ❑ Check Slope
❑ Surface water
❑ Check cellar '
❑ Shallow wells
Estimated depth t high ground water: feet e
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:
Auger T.H. at 11' no G.W.. Bottom of pit at 8' below grade. Bottom of pit of T above T.H..
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
151ns-3713 Title 5 Official Inspection Form:Subsurface Sewage Disposal Syslem-Page 16 of 17
Apr 07 2016 21:36 Jim The Inspector Man 5085349919 page 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
31 Fifth Ave
Property Address
Karen Giatrelis
Owner Owners Name
information is West Hyannisport MA 02672 4-7-16
required for every
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® inspection Summary: A, B, C, D, or E checked
P rY
® 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
Mns-3113 Title 5 Official Inspection Form:SuWurlaoe Sewage Disposal Syslem-Page 17 of 17
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
kq Jr.
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5 T
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
r CERTIFICATION
CP
F
Property Address: 31 Avenue
W. Hyannisport
Owner's Name: John Diamond
Owner's Address: 13 Hi 1 1 crest Road
9,1iffrPny NY 1 ngn1
Date of Inspection:
Name of Inspector:(please print) William E_ . Robinson Sr.
Company Name: William E. Robinson Septic Service
Mailing Address: P O Box 1089
Centerville, MA
Telephone Number: i S O 8 l 7 7 5-tl7 7 6
CERTIFICATION STATEMENT
1 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 15340 of Title 5(310 CMR 15.000). The system:
L,A asses
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 411"j ,, Date: —.z ie—d 6
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Heanh-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 approxing
authority.
Notes and Comments
""This report only describes conditions at the time of inspection and under the conditions of use at that
time.This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
l
Page 2 of 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 31 5th Avenue
W. Hyannisport
Owner: John Diamond
Date or Inspection: --p
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all orSeetion D
A. Syst Passes:
I have not found any information which indicates that any of the failure criteria described in 310 CMR
15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below.
Comments:
B. System Conditionally Passes:
One or more system components as described in the"Conditional Pass"section need to be replaced or
re aired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass.
Ans er yes,no or not determined(Y,N,ND)in the for the following statements.If"Wort determined"please
expla
e septic tank is.metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsoun ,exhibits substantial infiltration or extrltration or tank failure is imminent.System will pass inspection if the
exisling tank is replaced with a complying septic tank as approved by the Board of Health.
•A meta septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance
indicaten that the tank is less than 20 years old is available.
ND expl in:
bservation of sewage backup or break out or Idgh static water level in the distribution box due to-broken or
obstru Idpipes)or due to a broken,settled or uneven distribution box.System will.pass inspection if(with
approv I of Board of Health):
broken pipe(s)are replaced
obstruction is removed
'distribution box is leveled or replaced
ND ex lain:
e system required pumping more than 4 times a year due to brokm or obsut. ed pipe(s).The system will
pass ins ection if(with approval of the IIoard of Health):
broken pipe(s)arc replaced
obsbuetinn is removed
ND cxp ain:
Page'3 of 1 I
OFFICIAL INSPECTION,FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 31 5th Avenue
W. Hyannispor
Owner: John Diamond
Date of Inspection:
C. Further Evaluation is Required by the Board of Health:
onditions:exist which require further evaluation by the Board of Health in order to determine if the system
is failin to protect public health,safety or the environment.
1. S stem will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
s tem 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.pnvy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. S stem will fail unless the Board of Health(and Public Water Supplier,if any)determines that the .
syste is functioning in a manner that protects the-public health,safety and environment:
The system has a septic tank and soil absorption system(SAS).and the SAS is Withim.l00.feet of
rface 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
rivate water supply well" Method used to determine distance .
s This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
b cteria and volatile organic compounds indicates that the well is free from pollution from that facility and
e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other.
f ilure criteria are triggered.A copy of the analysis must be attached to this form.
3. (her:
3
Page 4 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM.
PART A
CERTIFICATION(continued)
Property Address: 31 5 th Avenue
W. Hyannisport
Owner: John Diamond
Date of Inspection:, — o
D. yslem Failure Criteria applicable to all systems:
You ust indicate".yes".or"no"to each of the following for all inspections:
Yes o
Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of effluent to the surface of the ground or surface' waters due to an overloaded or
clogged SAS or cesspool
Static liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or
cesspool
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 l of a.public'well.
Any portion of a cesspool or privy is within 50 feet of a privatewater supply well.
_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 t et from a private Kato
supply well with no acceptable water quality analysis.(This system passes if the well water analysis,
performed at a DEP certified laboratory.,for coliform bacteria and'volatile organic compounds
indicates(hat the well is free.from pollution from that facility and (lie 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: arge Systems
T be onsidercd-a large system the system must sen•ea facility tvilh`a`aesign flow of]0;000 gpd to 151000
d.
You mu t indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary-to a surface drinking water supply
the system is located in a nitrogen sensitive area(interim Wellhead Protection Area-IWPA)or a mapped
Zone 11 of a public water supply well
If you ha ye answered"yes"to any question in Section E the system is considered a Significant threat,or answered .
"yes"in ection D above the large system has failed.The vvmer or operator of airy large system considered a
signific nt threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304 The system owner should contact the appropriate.regional office of the Department.
4
Page 5 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 31 5 th Avenue
W. Hyannisport
Owner: John DiamoncL
Date of inspection: L
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`baffleles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
_L✓ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been-determined based on:
Yes no
Existing information.For example,a plan at the Board of Health.
Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)j
5
Page 6 of I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 31 5th Avenue
W. Hyannisport .
Owner: John Diamond
Date of Inspection:
FLOW CONDL`I'IONS
RESIDENTIAL
Number of bedrooms(design): Number of bedrooms(actual):
DESIGN flow based on 310 CMR 1 .203(for example: 110 gpd x N of bedrooms): Ci
Number of current residents:
Does residence have a garbage der(yes or no):L6
Is laundry on a separate sewage system(yes or no):ko[if yes separate inspection required]
Laundry system inspected(yes or no)�tl
Seasonal use:(yes or no):��.,
Water meter readings,if available(last 2 years usage(gpd)): 0 4/0 5 — 9750
Sump pump(yes or no): p 0 5 0 6 — 6000
Last date of occupancy:
COMM ERCIAIANDUSTRIAL
Type of establi ent:
Design flow( ased on 310 CMR 15.203): - gpd
Basis of des' flow(seats/persons/sgft,etc.):
Grease tra resent(yes or no):_
Industrial aste holding tank present(yes or no):_
Non-s tary waste discharged to the Title 5 system(yes or no):_
Water eter readings,if available:
Last to of.occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part o e inspection(yes or no):_
If yes,volume pumped: Rallons--How was quantity pumped detern►ined?
Reason for pumping:
TY1OF 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/Altemative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
_Tight tank Attach a copy of the DEP approval
—Other(describe):
Approximate age of all compone is,date installed(if kn n)and source of information:
12,
Were sewage odors detected when arriving at the site(yes or no): Al O
6
I'a6c 7 of I I
OFFICIAL INSPECTION F0101-NOT FOR VOLUNTARY ASSLSS111ENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYS•I BI INFORMATION (continued)
Property Address: 31 5th Avenue
W. Hyannisport
Owner: John Diamond
Date of Inspection:
BUILD, G SLNUR(locate on site plan)
Dcpdt Clow grade:
Materi Is of constion:_cast irun _4U PVC_odic,(explain):
Dista .ce from Private water supply well or suction lint:_
Comments(oil condition of juutts,venting,evidence of leakage,etc.):
SL'PTIC TAnK:_(locate on site plats)
bcplh below grade:
Material of Construction: ncrete metal fiberglass JrulyeU►ylene
_uthcr(cxplain) — —'
If tank is metal list age:_ Is age cunftrnled-�y a Certificate of Cungrliance()Cs or nu):_(attach a culrj of
certificate) I�
Din►ensions: L A�
Sludgc dcplh:
Uistancc boll,lull of sluJ6c to lwuurn of outlet tee of bafllc: 3
01
Sctutt thickness:_ �yl�- L
Distance front lull of scull,to Iop of outlet Ice or bafllc: I
Distance boat bultunt of scum to buttons of uutict tcc or battle:
low sscre dimcnsiuns dctcnnincd:
Cumntents(un pumping teeouunendatiuns, inlet and vutict tee or ballle eunditien, sit uctwat integrity,liquid levels e
as related to PCs outlet invert,evidence of Ica age,etc.):�
GREASE TM :_(Iocalc un site plan)
Dcpol below adc:_
Material of co structiun:`cun(tctc metal fibctglass_pulycdll)•Icttc _odder
(o,plaut): -- --
Dimcnsions
Scum Chic css:
Distance[r m top of scuitt to top of uutict Icc or bafllc:_
Distance ont bottom of`scutl,to bullum of uutict Ice or bafllc:
Date of I st pumping:
Co Witt: Is(Oil pumping rccunurtcndatiuns, inlet and outlet tce or bafllc cunditiu:I,situctutal integrily,liquid level,
as rclal d 10 oullcl imar,Uldcncc of leakage,c1c.):
7
I
' I
Page 8 of
OFFICIAL INSPECTION FOim NOT FOR V0LUNTAI0' ASSL•'SSMLNTS
SUUSUIWACE Sl;1VAGL DISPOSAL SYSTEM INSPEICTION F011,n1
PART C
SYSTl;111 INFOIUTATION(conlinucd)
ProperIyAddress: 31 5th Avenue
H annis ort
Owner. d
Dale of lospccllon:
TIGHT or 11OLD1NG ANK: (tank must be puni)cd al time of it ,rsl eclion)(Ivcalc un site ,flan)
Depth below grade;
h 1alcrial of construe on:`_concrete_metal_fiberglass_lrulyelhylene_ollter(explain):
Dimensions
Capacity: allvns
Design Flow; allun /
6
sJa •
Alan's present )sent
p yes or no):
Alarm h:vel; Alann in wurkin d
Date of last um P g�in 6 older (yes or nu):
Cununcnls condition of alarm and float swilclres,cit.):
UISTIl1UUTlON U
Oa.
zorlucsCIII nw st be opcncd)(localc on site I,tan)
Depth of liquid level above oulict invert:
Conullcnts(note if box is level and distribution lv oullcls equal,any evidence of solids carr�•over,any evidence
leakage into or out of box,ctc.). of
P UAW CII IDEA:`(locate on site ,Ian
Pumps in eurking order(yes or no):_
Alarms t s�orkin9 order(yes ur no): _
Culmll nts(Ault condition of pump chamber,condition of pumps and appurtenan(es,ctc.):
Page 9 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 5th Avenue
W. hyanntspurt
Owner: John Diamond
Date of Inspection: e� y . g i 6 Q
SOIL ABSORPTION SYSTEM(SAS): 1/(locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
leaching.chambers,number:
leaching galleries,number:
leaching trenches,number,length:
leaching fields,number,dimensions:
overflow cesspool,number:
innovative/altemative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation,
etc.):
ra L�
CESSP OLS: (cesspool must be pumped as part of inspection)(locate on site plan)
Numb r and configuration:
Dep —top of liquid to inlet invert:
Dep of solids layer:
De h of scum layer:
Di ensions of cesspool:
M erials of construction:
In ication of groundwater inflow.(yes or no):
mments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY- (locate on.site plan)
Mater' is of construction:
Dime ions:
Dept of solids:
Co ents(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page 10 of 1 I '
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY'ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 5th Avenue
W. Hyannispor
Owner: John Diamond
Date of Inspection: �6
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.
JA
3
� � i✓1
10
Pagc j l of l l
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 31 5th Avenue
W. Hyannisport
Owner. John Diamon
Date;of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to groundwater feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-if checked,date of design plan reviewed:
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 mu �sc be how you established the high ground water elevation:
� l 6 YY
11
TOWN OF BARNSTABLE
� LOCATION SEWAGE #
VILLAGE SSESSOR'S MAP & LOT
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY:(type) r (size)
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER
DATE PERMIT ISSUED: �' '' l
DATE COMPLIANCE ISSUED: Z
VARIANCE GRANTED: Yes No
�' U � M
h
-� ��A
v �''
� C`�
e T�
�.
� M /I
4
�•
4 V_
1
No----.� FEs.. .. o......
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
TOWN OF BARNSTABLE
Apphratinn for UWpnsal Works Tnnstratiinn famit
Application is hereby made for a Permit to Construct ( ) or Repair (Individual Sewage Disposal
System at:
.......... ....irk----------------------------- -------------�---- c�vvs. a ........-
�}-� / Location�-Address or
----------------------------- --------_-•---------- ..�.�-o---No----------•----------------------•--'-----
...-------�7.`1^.1O-G1.�...1.� �.xc.�Yam...•- � ��X Y)Y.-.-...( �( '^^ �/��
Id
nes� ...��Lc-------------------- --------------0.0 _ 60� .... e-4..`4+ Y:k�.Y.:k�d ......
a Installer Address
Type of Building Size Lot----------------------------Sq. feet
V Dwelling_No. of Bedrooms.... ------------------------------------Expansion Attic ( ) Garbage Grinder ( )
Other—T e of Building No. of persons............................ Showers — Cafeteria
Pa Other fixtures ---•-----------•-----------------------------••--
W Design Flow......-.6.........................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.
l
Seepage Pit No.___._I-------------- Diameter-----1Q_c.__._--- Depth below inlet...CO. .......... 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........................
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
R+' --•••••-------------•--••••-•-•-•••••••••---•••-•••-••••-----••-••-••-•--•-•....--•-----------------.........................................................
0 Description of Soil---------------------------------------------------------------------------------------------------•------------------------------------------------------------------
x
W -•-•••-•••••-- ......................................................................................................................... T .........................................................
a Nature of Re airs or Altera ions—Answer when ap livable___- 1 �� 1 �L____l__ ._ ..`C_b �
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 Com lia bee issued bv the and of health.
Signed . ----- ------
dew+ } Date
Application Approved By ................. U....-
Application Disapproved for the foaw
llowing reasons- ------------------------------------------------------------------------------------ -------- ----------------------- ---------
- - - ------------------------------------------- ---- . ---------------
// Date
Permit No. .,GC��//....'-&--- _------------------- Issued ----.................................................... ...
Date
No
Fzz
..o s
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliration for Disposal Works Tons rnrtiun V&ntit
Application is hereby made for a Permit to Construct ( ) or Repair an Individual Sewage Disposal
System at:
--........ I_____........r--T �v --------------------------- ..............Lev____ _ram..-..----
Location-Address or Lot No. ti
?.W.1!c�_ -----------•-----------•-- ..........__-----------
__ _........................................-.-..---
Owner _ Ad ess
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms_____ __________________ Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ____________________________ No. of persons............................ Showers ( ) — Cafeteria ( )
Pa Other fixtures ---------_-------_-------•••-•-•-••••••••-••• .
W Design Flow____._:_i ________________________gallons per person per day. Total daily flow...... .....................gallons.
WSeptic Tank—Liquid capacity/ gallons Length...FC__........ Width.... Diameter________________ Depth................
x Disposal Trench—No_____________________ Width____..__.____._____ Total Length.................... Total leaching area--------------------sq. ft.
Seepage Pit No......I-------------- Diameter-----Ln__------- Depth below inlet---(Q............ 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........................
P4 -----------------------------------------------
----------------------------------
•----------
-----------------------------
_..................................
0 Description of Soil-------------------------------------------------------------------------------=--------------------------------------------------------------••-----•----•-•-----•••--
x
U ----------------------------------------------------------------------------------•-----_______-----____-___--------- ------------------
-•-----------
W '��
V Nature of Repairs ,rAlterations Answer when applicable...... ...
N. _ �
-------------(9_e- --- ... u'j v K -:__._.... - L?....---------------•---------------------•-----•------------------------------.......----•
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 Com liance as bee issued ly the oard of health.
Date
Application Approved BY =tom•^-��..-``'-s-----------------_--------------------------------------- --------� � ---{/
te
Application Disapproved for the fo lowing reasons- -------------------------------------------------------------= -------------------------------------------------------------------
Q Date
PermitNo. ------. -.......... ......... Issued --------------------------------- ------------------
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
C11elti#ira e of Cgumylian*rr
THIS IS T[/^O CERTIFY,
(That the Individual Sewage Disposal System constructed ( ) or Repaired
by.. .!"`.��.... .!T.-...''JD...s-�..1p-Ti.7` ..---Installer —.-.......................................------------ ---------_ — — — — —----------......-.-... -- --- -- ---- ---'------------------
at ......................�Z------1----------------�—�.j s. c •------....... -. ..c�.f. {1 C� ?1f?.� _----------.------- .---
has been installed in accordance with the provisions of TITLE 5 o The State Environmental Code as described in
the application for Disposal Works Construction Permit No- -------- .. .�..........-- dated ................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE-CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY. ✓,
6� t� ��
DATE .... '---��-_-- .................... Inspect=r_---- -'----- --- -----------
s
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE FEE.,.1_� _:..
Disposal Works Tonstrnr#ion fermis
Permission is hereby granted.---..�..A4P.K._L,PQN.0.....Sr�_C.._..-•..........................................................
to Construct ( ) or Repair (,_)_alr-Individual.Sewage Disposal System
at No..........3,_k sC� ,�` 1-- .u!C- ---------•-- -!!-1 `= •�`r rti rat a.� - �
Street _as shown on the application for Disposal Works Construction Permit No._. __�.//2 Dated..........................................
Board of Health
DATE. -------- ...--�2 - /-----------------------•------•
FORM 36508 HOBBS 6 WARREN.INC..PUBLISHERS
1