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HomeMy WebLinkAbout0017 GREGOIRE CIRCLE - Health 17 Gregoire Circle Hyannis'° '• A = 273 013 i TOWN OF BARNSTABLE L'OCAT`?N f 6 E ! XE COC 4' SEWAGE # )aII.Y"AGE rcp ' �YADYN�S ASSESSOR'S MAP & LOT ,r(�/ — - - INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY ��^'� -/x LEACHING FACILITY: (type) ,ice �` (size) NO. OF BEDROOMS BUILDER OR OWNER t PERMITDATE: /02t:- COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ` Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by . � � � � � ';� ti o� � - � � V�. � �,- �`' `'� � w i' , ' �' l / ' i I � � f. �' � - � , �� � � , � ,�j - O -I � o n i� 1. -, L `. � `� r _ ���,, � .�. - . ��. �1 i- -- . --- 1 R; �. ; h. ��~ �J 013 Commonwealth of Massachusetts F,-- I Inspection Form . Title 5 Official 'I - - -Not for Voluntary Assessments 74 - Subsurface Sewage Disposal System Form 17 Greqoire Circle Property Address ioyqe_Gresh Owner Owner's Name information is r- (I 1 4/18/17 -d for every ��,fltervft MA 02632 require jjjq 110- State Zip Code Date of Inspection page. City/Town 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 A. General Information 1 ,2-283 filling out forms on the computer, use only the tab 1 Inspector: key to move your cursor-do not Mike DeCosta Jr._ use the return Name of Inspector key. Wind River Environmental tcl Company Name 46 Lizotte Drive Suite 1000 Company Address EA MA 01752 Marlborouqh --------- State Zip Code 800-499-1682 --SI 1-3-231O.-I-.---.----.-..-,-.-----.-.--- ------- 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 F-1 Needs Further Evaluation by the Local A roving Authority pn re I pector's ignature Date /The system inspe or shall submit a copy f this inspection report to the Approving Authority(Board of or P) 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 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.doc-rev.6/16 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 /0,90M V's Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments u 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is Centerville MA 02632 4/18/17 required for,every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Both covers 14" below grade, no filter installed on outlet. 13) 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.doc-rev.6/16 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 _ 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is required for every Centerville MA 02632 4/18/17 page. City/Town 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,falarms 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 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 I� Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments . 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is required for every Centerville MA 02632 4/18/17 page. Cityfrown 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 1/2 day flow t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is required for every Centerville MA 02632 4/18/17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is required for every Centerville MA 02632 4/18/17 page. City/Town State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 3 Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is required for every Centerville MA 02632 4/18/17 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: n/a 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 unavailable 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CM 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is Centerville MA 02632 4/18/17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,.w 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is required for every Centerville MA 02632 4/18/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Approixmately 30 years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 20 feet Material of construction: ❑ cast iron ❑ 40 PVC n/a - see below ❑ other(explain): Distance from private water supply well or suction line: n/a -see below feet Comments (on condition of joints, venting, evidence of leakage, etc.): Did not have permission to enter basement to check piping, homeowner not present during inspection. Septic Tank(locate on site plan): Depth below grade: 14" 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: 8'x5'x4' Sludge depth: 8" t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is Centerville MA 02632 4/18/17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 32 Scum thickness 2 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? The dimensions were determined by sludge judge, rod, and ruler. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Both covers 14" below grade, tees in good condition, no filter installed, liquid level normal, light solids, heavy sludge, tank appears to be structurally sound, not leaking. Highly recommend installing a riser on outlet cover with the use of a filter, tank should be pumped yearly. 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.doc-rev.6/16 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 M a 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is required for every Centerville MA 02632 4/18/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins.doc•rev.6/16 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 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is required for every Centerville MA 02632 4/18/17 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 11 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.): On riser 1' below grade, box size 16"x16" one outlet to leach pit, liquid level normal, heavy sludge carryover into box, box showing moderate signs of deteroriation, box is in good structural condition, water tight, not leaking. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °.w 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is required for every Centerville MA 02632 4/18/17 page. City/Town State Zip Code. Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1 -6'x6' ❑ 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.): Pit is 2' below grade, pit has 52" of liquid in it, pit has 18"of available space, no evidence of high stains, showing no signs of hydraulic failure, vegetation normal. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is Centerville MA 02632 4/18/17 required for every page. City/Town 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.): t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Gregoire Circle Property Address Joyce Gresh -------.__-- Owner Owner's Name information is Centerville MA 02632 4/18/17 required for every — page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to ataeast two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate Wheie public water supply enters the building. Check one of the boxes below: t lan -setc3 x in tte area below dGw1np�adacd separately 1Q- A -TG 2- - :3 Z,L' el N, I Q t t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,M 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is required for every Centerville MA 02632 4/18/17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 11 + feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: 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: Approximately 1 V to the bottom of stone in pit, pumepd pit and observed no ground water inflow. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 1 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 17 Gregoire Circle Property Address Joyce Gresh Owner Owner's Name information is Centerville MA 02632 4/18/17 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 ® 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 i t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 a 7THE Fee COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Z(vurication for Miopooar 6potem Congtruction Permit Application for a Permit to Construct( )Repair(. Upgrade( )Abandon( ) O Complete System ❑Individual Components Location Address or Lot No. Grey°,rL C�� Owne 's Name,Address and Tel.No. �7 /yt kc Kcnncc� Assessor's Map/Parcel / �A 11/l Installer's Name,AddreA aAd 9l.UNCO Designer's Name,Address and Tel.No. 350 Main Street Sv iVw01) EKC, , W. Yarmouth, MA 02673 Type of Building: Dwelling No.of Bedrooms 13 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets / Revision Date A/TI�- Title AP 41L) Size of Septic Tank /OQn I in Type of S.A.S. _ T 4 C`i.4*i is Description of Soil Nature of Repairs or Alterations(Answer when applicable) P . NrINEER MIDST SUP R IS— r^.,.�.0 ,v«7 AID0 C2RTIFYsv vu,sj fiitia TFS.� f f:i�P_Nfi WAS J�I T 1 1 C.7',-Y' y� F, Date last inspected: CCORDANCE TO PLAN. • .� Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of lth. Signed / Date 7 11-2/4 Application Approved by Date Application Disapproved for the following reasons /1117 Permit No. Date Issued �I r i` •. THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: 4 Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS Zipplication for �Dil5pool *pMem Construction Permit Application for a Permit to Construct( )Repair(vgrade( )Abandon( ) ❑Complete System ElIndividual Components { Location Address or Lot No. /"? �� O r (�'' T Owner's Name,Address and Tel.No. Assessor's Map/Parcel ! Installer's Name,Address, d 1 o Designer's Name,Address and Tel.No. i A V M CANC© ,S�t I i •�aJ a t - 350 Main Street �? W. YarrnoU4b,, M Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons ''' ? a Showers( ) Cafeteria( ) Other Fixtures Design Flow J gallons per day. Calculated daily flow gallons. Ga Plan Date; f 5 d. ' Number of sheets Revision Date A..)�/* Title ,.. ,4 1 .Size Id Septic Tank /I cav E.,e;j4l,% Type of S.A.S. b 0 fd L e-AA,7,117 t X 1 J Description of Soil J Pe�'t tip►%� Nature of Repairs or Alterations fAnswer when applicable)' l''I A-hl Date last inspected- is Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Board of eealth._ .. . Signed /) Date 7 Application Approved by Date Application Disapproved for the following reasons Permit No. Date Issued -----------—------------ -- ---------- I` THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed( )Repaired( (,4 pgraded( ) Abandoned( )by d at /7 fe o/h t f i f, I iA 7 has.bep constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NA ; dated W,'7 �t Installer Designer The issuance of this-p -t shall of be construed as a guarantee that thusgeA will fun�tio as de gned j Date U Inspect( r �� Q i • -- ------------------------------- `77 No. f/ Fee v ' THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLEIS► THE T!ON AND CERTi ST SUPeF?VISe liopozar *pMem Con�tructtap S INSTALL SIN WFjITING Permission is hereby granted to Construct( )Repair(1,/rrpgrade( )Abandon( ) PLAN. IN STRIC-' System located at 1-7 e!57E "In < rP C"'r I•'. .�t?�?f S ' 4 and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction ithin three years of the date of thi �e Date: / ` �� Approved by / TOWN OF BARNSTABLE LOCAn(�`!N ®.v--u.O t\'.s- �puZ. SEWAGE # 1 VILLAGE ASSESSOR'S 'MAP & LOT `—) - bl INSTALLER'S NAME PHONE NO. HtCXj5i fttg.,Z; ?— y/ Z g SEPTIC TANK CAPACITY LEACHING FACILITY:(type) NO. OF BEDROOMS _PRIVATE WELL PUBLIC WATER BUILDER O WNER --Toys)Es DATE PERMIT ISSUED: b 'i DATE COMPLIANCE ISSUED: -4'y VARIANCE GRANTED: Yes No �� O �` 6 O- ,. '�. _� �,, ",►' �� `� LOCATION SEWAGE PERMIT NO. V.y-1 LAG E INSTA LLE.R'S NAME & ADDRESS BU11DER OR OWNER 1. 0 7- DATE PERMIT ISSUED �� ���, ��,�' DAT E COMPLIANCE ISSUED A i I Sullivan Engineering Inc. 7 Parker Road,Box 659,0sterville MA 02655 508428-3344 e-mail:usullye ar,aol.com fax 508-428-3115 August 20,2002 Town of Barnstable Board of Health 200 Main Street Hyannis,MA 02601 RE: Kennedy/Gregoire Circle,Hyannis Dear Board of Health, Per the conditions of the Septic Permit I performed an on site inspection of the above referenced project. I found that the soil was suitable for the leaching field,and that the system was installed in substantial compliance with the plan of record with the following exception: - The installer choose to use the existing septic tank instead of installing a new 1500 Gal.H-20 tank as per the plan. Please note that despite the exception the system is still in compliance with Title V, and we hereby request that you issue the Certificate Compliance to the installer or homeowner. I trust this meets your present needs. Please feel free to call if you have any further questions. Very truly yours EP�— John O'Dea,E.I.T. Sullivan Engineering Inc. Cc: James Moore Members of The American Society of Civil Engineers and The Boston Society of Civil Engineers V TOWN OF BARNSTABLE LOCATION 1°7 CEG�1/ SEWAGE # VILLAGE ��" t� ���� AS*SSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. /r. Co4lvco 72-5` 6 SEPTIC TANK CAPACITY LEACHING FACILITY: (type) �� — ` (size) . 3• �X J.x NO.OF BEDROOMS BUILDER OR OWNER C Sqv PERMIT DATE: C��- COMPLIANCE DATE: /J —,;-O- Q� Separation Distance Between the: Maximum Adjusted Groundwater Table-to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by / } i t i t ; 1 i � M E vluE L� � • _ �J � ��✓�-. ��'' /Q�i�,:t Vim. <�'��'�">� i�y'.�, �` .� ! ` -._,..a.�" I ��/'„� Cam, '�, -�"�t'.ad � �' T 3 `,j'�rA//�C-� �•' I ! 0 -5 I1vV/ IAIV, _ r i /�'} �3-(.- Cam"����'%G_, .�� ,�/ q •_ � � � � { - iOFr.->,I n/7'/c)A,l 4-7- -TJdjE <�r StH.LwtlOU - W.287n d, }; c ipyf8. E� I + •! :� -. � vim. `���V�'^•��w `« '�r^rat`:. t3 t �1. �/ QY1 ,