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Home My WebLink About0040 HAMDEN CIRCLE - Health 40 Hamder.�Y�� Hyannis --- x. A = 291 184 F/R e a o Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Property Address Dennis Perry Owner Owner's Name information is required for every Hyannis Ma 02601 3/12/2021 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. Inspector Information ( _ on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 lane � Company Address Address Centerville Ma 02632 City/Town State Zip Code 774-2484850 smjonestitle5@gmaii.com, SI4522 sean@smjonestitle5.com License Number B.'Certification I certify that I 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 the property 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 Au rity 4. ❑ Fails 3/12/2021 Inspectors 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.doo-rev.7/P MIS Tide 6 Official Inspection Form:Subsurface Sewage Disposal System•Page t of 18 Commonwealth of Massachusetts -. Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Property Address Dennis Perry Owner Owner's Name information is required for every Hyannis Ma 02601 3/12/2021 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: ® 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 property located at 40 Hamden Circle Hyannis is served by a Title V septic system consisting of a 1000 gallon septic tank, distribution box.and 4 Infiltrators. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) 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): t5insp.doc•rev.MGM 8 r Titre 5 011i dal Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Property Address Dennis Perry Owner owner's Name information is required for every Hyannis Ma 02601 3/12/2021 City/Town page. State Zip Code Date of Inspection C. Inspection Summary (cons.) 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 ❑ 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): 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.7/25W 8 We 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Property Address Dennis Perry Owner Owner's Name information is required for every Hyannis Ma 02601 3/12/2021 . 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.MM2018 T ft 5 Offidal Inspection Forth:Subsurface Sewage Disposal System•Page 4 o/18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Property Address Dennis Perry Owner Owner's Name information is required for every Hyannis Ma 02601 3/12/2021 page. Cityrrown 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 Y2 day flow ❑ ® 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. ❑ ® 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 11 of a public water supply well t5insp.doc•rev.7P26=8 Tits 5 Official Inspection Form:Subszface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Property Address Dennis Perry Owner Owner's Name information is required for every Hyannis Ma 02601 3/12/2021 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (con. t.) 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 thel 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)] t5inspAoc•rev.7r2812018 Tate 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle. Property Address Dennis Perry Owner Owner's Name information is required for every Hyannis Ma 02601 3/12/2021 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 flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Description. 2 Number of current residents: Does'residence have a garbage,grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes 0 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 [D No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes. ® No Last date of occupancy: current Date t5insp.doc•rev.MAW 8 Title 5 Official Inspection forth:Subsurface Sewage Dispoaet System•Page 7 of 16 f Commonweal of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Property Address Dennis Perry Owner Owner's Name information is required for every �annis Ma 02601 3/12/2021 page. City/rown 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): -- 1 3. 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: tShsp.doc-rev.7rM2018 Title 5 Official Inspection Form:SubsLuface Sewage Disposal System-Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Property Address Dennis Perry Owner Owner's Name information is required for every yH annis Ma 02601 3/12/2021 page. Cityrrown 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/Altemative 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: Tank original 1978, system repaired 2/26/2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): 2 Depth below grade: 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.): Joints in good condition, no leakage, vented through roof. i tSump.doc•rev.7 WDI8 T&le 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 C III ommonwealth of Massachusetts 02 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Property Address Dennis Perry Owner Owner's Name information is H required for every Hyannis Ma 02601 3/12/2021' page. cityfrown state Zip Code Date of Inspection D. System Information (cunt.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 feet Material of construction: ®concrete ❑ metal ❑fiberglass ❑ polyethylene y ❑ 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 gallons Sludge depth: 5" Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 711 Distance from bottom of scum to bottom of outlet tee or baffle 10" -- How were dimensions determined? Opened covers and took measurements 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 should be pumped soon and again every 2 years for proper maintenance.water level was even with outlet, tank was not leaking and was structurally sound. Inlet and outlet covers are on risers t5insp.doc•rev.7/2612D18 rate 5 Offidal Inspection Form:Substnface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection, Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Property Address Dennis Perry Owner Owner's Name information is required for every Hyannis Ma 02601 3/12/2021 City/Town page. 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 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 t5insp.doc•rev.7/281P018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Property Address Dennis Perry Owner owner's Name information is Hyannis required for every �_ Ma 02601 3/12/2021 pap. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in wonting 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.): Distribution box was level and in good condition with no rot.Water level was even with outlet invert with no signs of past backup. t5lnsp.doo•rev.7n6M 8 Title 5 Of lal lnspadlon Form:Subsurface Sewage Disposal System.Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Property Address Dennis Perry Owner Owner's Name information is Hyannis Ma 02601 3/12/2021 required for every page. Cityfrown 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: ® leaching chambers number. 4 Infiltrators ❑ leaching galleries number ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: i t5insp.doc-rev.7/262018 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts U Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle ; Property Address Dennis Perry Owner Owner's Flame information is y Hyannis required fore _Y Ma 02601 3/12/2021 page. Cityfrown 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.): s.a.s. consists of 4 Infiltrators in a 33'xl 12'trench. Leaching facility was video inspected from vent and was found dry with no signs of past overloading. 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.doa•rev.7I M018 Title 5 Official Ins pection Form:SubstMaae Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Property Address Dennis Perry Owner Owner's!dame information is H required for every y annis Ma 02601 3/12/2021 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.): t5v sp.doc•rev.MGM 8 Tdb 5 Offidal hspe w Formi SLbsurface Sewage Disposal system•Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Properly Address Dennis Perry Owner owner's Name information is Hyannis required for every y Ma 02601 3/12/2021 page. Citylrown State Zip Code Date of Inspection D. System Information (cunt.) 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 a!a 3 2 4 AZ tIto. A3 t t5insp.doc rev.7r26W18 Title 5 Offiaal Inspection Form:Subsurface Sewage Disposai System•Pape 16 of 18 Commonwealth of Massachusetts �9Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments w) 40 Hamden Circle Property Address Dennis Perry Owner Owner's Name information is required for everyy H annis Ma 02601 3/12/2021 page, Cityrrown 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) El. 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: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5insp.doc•rev.7P26=8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 40 Hamden Circle Property Address Dennis Perry - Owner Owner's Name information is required for every Hyannis Ma 02601 3/12/2021 page. Cityrrown 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@8W 8 Tile 5 Offmial Inspection Forth:Subsurface Sewage Disposal system•page 1s or is �Y TOWN OF BARNSTABLE LOCATIONo ��/�trd�ti /�<« 'ySEWAGE # �'oo,Z Q7y ' III LLAGE �e ',Of f'/-P ASSESSOR'S MAP & LOT'Z 9/ 8 INSTALLER'S NAME&PHONE NO.�jIw e l;BoEi,� 99t 7 SEPTIC TANK CAPACITY �o o e c9'4�• LEACHING FACILITY: (type) S' '�Z� �'"��L�iP-�Tarl (size) NO. OF BEDROOMS 3 BUILDER OR OWNER PERMITDATE: '�r' '� 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 0,/A— 1 tb Ly � b Q\ 41N , � x a r O � n c �i . TOWN OF BARNSTABLE LOCATION CIO NAM f],n C�rL� SEWAGE # VILLAGE uy�gnnl s ASSESSOR'S MAP & LOT 4ARY- INSTALLERS NAME&PHONE NO. Fn INSP ;TIO SEPTIC TANK CAPACITY CNb LEACHING FACILITY: (type) ��T �X(o, (size) C/ NO. OF BEDROOMS 3 BUILDER OR OWNER c,�Ar� lNA lea- PERMITDATE: 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 leac 'ng facility) Feet Furnished byT� Uh �p�� r' L 3 1 t � � r a' THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _TuX Yes PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS 0(ppIication for 13iopooar bpotem Congtruction Permit Application for a Permit to Construct( )Repair( )Upgrade X Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No._ �i3 y .✓ G/D?G�� f71//h� :.�/c',-�✓scv2,� /�.;«,cc.G Assessor's Map/Pazcel Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. _YJ .2 7, Type of Building: Dwelling No.of Bedrooms Lot Size sq�. Garbage Grinder( ) Other Type of Building op Ff; No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow 3�� gallons per day. Calculated daily flow 2-1 O gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank ---Type of S.A.S. y �'`�" C�� ji�Fi�i'�e7'•rz r' yp Description of Soil Nature of Repairs or Alterations(Answer when applicable) Y Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this Board of Health. Signed Dated"o Application Approved by Date `Z Application Disapproved for the following reasons Permit No. Date Issued :o�— '_;_Es �S�� i TOWN OF BARNSTABLE �L LOCATION y'!/'t/�.dcr�fi /�<« "ySEWAGE # °�04'7 VILLAGE !;�e '�l�"'� ASSESSOR'S MAP & LOT'Z 9/ 8 INSTALLER'S NAME& PHONE NO. SEPTIC TANK CAPACITY �� • j y�o /.v�vtTii�-/Tait s1'LEACHING FACIL.I'I'Y: (type) (size) NO. OF BEDROOMS I BUILDER OR OWNER PERMITDATE: �—'r� COMPLIANCE DATE: _d 40'eat 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 exit on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands'ezist within 300 feet of leaching facility) Feet Furnished by C7"/ 0 0 Y�✓r A �'�' ,9A 4 a l� �x � ; 49�' , C ems' J .ate- ♦ 7 ' No.A ,0'0 f�'` Feett;�� THE COMMONWEALTH OF MASSACHUSETTS Entered in co Yes �.',,PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS � t Zippfication for Migozar *p!6tem Construction Permit Application for a Permit to Construct Repair Upgrade )Abandon - pp ( ) p ( )Upg (� ( ) O Complete System El Components � Location Add ss or Lot No. Owner's Name,Address and Tel.No. o,y� �.✓ �io�cLP fiy, �� -C Assessor's Map/Pazce1�9 ! Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. may/,p, Jjj�(,j�ow 7/'e�Tly L N �y��• ; D,�C F�i'l, p/1,1a''►'1`"� •dfi(l P .2 "9, Type of Building: ;) x Dwelling No.of Bedrooms Lot Size sq.'\ft. Garbage Grinder Other Type of Building No.of Persons —Showers( ) Cafeteria( Other Fixtures Design Flow 3 9� gallons per day. Calculated daily flow 3 ""� gallons. Plan Date Number of sheets Revision Date Title � Size of Septic Tank �0470 ��AL Type of S A.S. '�� / �`"� c? Description of Soil , if k Nature of Repairs or Alterations(Answer when applicable) GP Ocr Tr 'TinF y . 5 Date last inspected' Agreement: - The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issue by this Board of Health. Signed � az�i.� Date Application Approved by Date sV-•-Ai-9 451- P 'Z Application Disapproved for the following reasons „ . w: Permit No.� ': �•G Date Issued ':;;7-•- 6- gz5 - f THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS (Certificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(x) Abandoned( )by �.7I^ l�.�G'yir at S/o /<A,*A&E/t^' A • has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit NRIJL 41� 7dated 0 Installer kT/A4 Designer 0,4 a'10' .6 /h.440^0 The issuance of this/permit shall not be construed as a guarantee that the syste i�•n will f nction as desed.._.�.-�- Date Z— ,2 ty 0 2 Inspector �/'�• / it"'". --------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS x1h5pogat *p5tem Con$truction Permit Permission is hereby granted to Construct( )Repair( )Upgrade&()Abandon( ) System located at G and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this U nnit. Date: " Approved i GCS 1 i 1 Commonwealth of Massachusetts Executive Office of Enviroiunental Affairs Dept. of Environmental Protection One winter Street Boston Ma. 02108 John Grad • . D.E.P. Title V Septic h>spector P.O. Box 2119 Teaticket,MA 02536 WILLIAM F.WELD (508) 564-6813 Governor ARGEO PAUL CELLUCCI f Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A J CERTIFICATION S Fp ~y ' Property Address: 40 Hamden Circle Hyannis Lot 81 Address of Owner: 1pw 2 19g7 Namof e oftInspector:John Graci/12197 (Ka hleenIf rCassie 4 r8,gr4&f I am a DEP approved system inspector pursuant to Section 15.340 of Title%(310 CMR 15.000) Company Name,Address and Telephone Number: 4 G 9 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: X Passes This inspection is based on criteria defined in Title V _ Condltiona P s5es code 310 CMR 15.303.My findings are of how the system is Needs F h Evaluation B the Local Approving Authority performing at the time of the inspection.My inspection does Y pP 9 tY not imply env warranty or guarantee of the longevity of the Fails septic system and any of its components useful life. Inspector's Signature: QA Date: 9115197 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. INSPECTION SUMMARY: Check A, B.C, or D: A) SYSTEM PASSES: I :F X I have not found any information which indicates that the system violates any of the failure criteria defined as in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: 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. The septic tank is metal,unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection;or the septic tank,whether or not metal, is cracked,structurally unsound,shows substantial infiltration or exfiltration,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 04127/97) One Winter Street • Boston,Massachusetts 02108 9 FAX(617)556-1049 0 Telephone(617)292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 Hamden Circle Hyannis Lot 81 Owner: Kathleen Cessie Date of Inspection:9112/97 — Sewaae backup or.breakout.or hiah.static water level observed.in.the distrihution box is due to a broken. or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if (with approval of the Board of Health). Describe observations. broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced —The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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 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 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 of water supply or tributary to a surface water supply. — The system has a septic tank and soil absorption system and is within a Zone 1 of a public watersuppiy well. — The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. — The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for col form bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method usedto determine distance (approximation not valid) 3)Other D] SYSTEM FAILS: You must Indicate either"Yes"or"No"as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage in facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged cesspool. SAS is in hydraulic failure. (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 40 Hamden Circle Hyannis Lot 81 Owner: Kathleen Cassie Date of Inspection:9/12/97 DJ SYSTEM FAILS(continued) 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 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Numbers of times pumped Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E] LARGE SYSTEM FAILS: You must indicate either"Yes"or"No"as to each of the following: The following criteria apply to large systems in addition to the criteria: The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECLIST Property Address: 40 Hamden Circle Hyannis Lot 81 Owner: Kathleen Cassie Date of Inspection:9/12/97 Check if the following have been done:You must indicate either"Yes"or"No"as to each of the following: _x_ — Pumping information was requested of the owner,occupant, and Board of Health. X None of the system components have been pumped for at least two weeks and the and the system has been receiving normal — flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. X — As built plans have been obtained and examined. Note if they are not available with N/A. X — The facility or dwelling was inspected for signs of sewage back-up. X — The system does not receive non-sanitary or industrial waste flow. _X_ — The site was inspected for signs of breakout. X All system components,excluding the Soil Absorption System,have been located on the site. X The 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. X — The size and location of the Soil Absorption System on the site has been determined based on The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of Sub-Surface Disposal Systens. X Existing information. Ex. Plan at B.O.H. X Determined in the field(if any failure criteria related to Part C is at issue, approximation of distance is unacceptable)[15.302(3)(b)] (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 40 Hamden Circle Hyannis Lot 91 Owner: KaWeenCassie Date of Inspection:9/1297 FLOW CONDITIONS RESIDENTIAL: Design flow: 330 g•p•d./bedroom for S.A.S. Number of bedrooms: 3 Number of current residents: 1 Garbage grinder(yes or no): Yes Laundry connected to system(yes or no): Yes Seasonal use(yes or no): No Water meter readings,if available:(last two(2)year usage(gpd): n/a Sump Pump(yes or no): No Last date of occupancy: nfa COMMERCIAL/INDUSTRIAL: Type of establishment: n/a Design flow:0 gallons/day Grease trap present:(yes or no) No Industrial Waste Holding Tank present:(yes or no) No Non-sanitary waste discharged to the Title 5 system: (yes or no) No Water meter readings,if available: n/a Last date of occupancy: n/a OTHER:(Describe) n/a Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System has not been pumped in the last year. System pumped as part of inspection: (yes or no)No If yes,volume pumped: gallons Reason for pumping: n/a TYPE OF SYSTEM X Septic tank/distribution box/soil absorptions system Single cesspool Overflow cesspool Privy Shared system(yes or no) ( if yes,attach previous inspection records,if any) I/A Technology etc. Copy of up to date contract? Other: APPROXIMATE AGE of all components,date installed(if known)and source information: 1977 Sewage odors detected when arriving at the site:(yes or no) No (revised 0427197) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40Hamden Circle Hyannis Lot et Owner: Kathleen Cassie Date of Inspection:9/12/97 SEPTIC TANK: X (locate on site plan) Depth below grade: 1' Material of construction:X concreate_metal_FRP_Polyethylene_other(explaln) If tank is metal, list age o . Is age confirmed by Certificate of Compliance No (Yes/No) Dimensions: L 9'6'H 5'7'UU 4'10' Sludge depth:3" Distance from top of sludge to bottom of outlet tee or baffle: 24" Scum thickness:4" Distance from top of scum to top of outlet tee or baffle:6" Distance form bottom of scum to bottom of outlet tee or baffle: ta^ How dimensions were determined: Measured Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) Septic tank and all components are structurally sound.Recommend pumping septic system every two years for maintenance. GREASE TRAP:_ (locate on site plan) Depth below grade: n/a Material of construction: _concrete_metal_FRP_Polyethylene other(explain) Dimensions: n/a Scum thickness:n1a Distance from top of scum to top of outlet tee or baffle:n/a Distance from bottom of scum to bottom of outlet tee or baffle: We Date of last pumping,va Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity, evidence of leakage,etc.) n/a BUILDING SEWER: (Locate on site plan) Depth below grade: te' Material of construction:_cast iron_40 PVC_other(explain) Distance from private water supply well or suction l OO- Diameter: 4'_ Wamments:(conditions of joints,venting,evidence of leakage,etc.) (revised 04/27/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 40 Hamden Circle Hyannis Lot 811 Owner: Kathleen Cassie Date of Inspection:9/f2/97 TIGHT OR HOLDING TANK: (locate on site plan) Depth below grade: n/a Material of construction:_concrete_metal_FRP_Polyethylene_other(explain) Dimensions: rde Capacity: n/a gallons Design flow: n/a gallons/day Alarm level:—n/a Alarm in working order?_Yes No Date of previous pumping: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) We DISTRIBUTION BOX: X (locate on site plan) Depth of liquid level above outlet invert: n/a Comments: (note if level and distribution is equal,evidence of solids carryover, evidence of leakage into or out of box etc.) 4box is structurally sound,by video inspection,did not dig up. PUMP CHAMBER: (locate on site.plan) Pumps in working order:(yes or no)No Alarms in working order(yes or no)_Yes Comments: (note condition of pump chamber,condition of pumps and appurtenances, etc.) nla (revised 04R7/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 40 Hamden Circle Hyannis Lot 81 Owner: Kathleen Cassie Date of Inspection:9/12/97 SOIL ABSORPTION SYSTEM(SAS):X (locate on site plan,if possible;excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: n/e Type: leaching pits,number: 1,000 gallon octagon leach pit leaching chambers,number:We leaching galleries,number: n/a leaching trenches,number,length: n/a leaching fields,number,dimensions:n/a overflow cesspool,number:n/a Alternate system: n/a Name of Technology:_n/a Comments:(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.) The leach pit is structurally sound and functioning property.It had 1.5'of water ink by video inspection did not dig up because it is under a pool. CESSPOOLS:_ (locate on site plan) Number and configuration: n/a Depth-top of liquid to inlet invert: n/a Depth of solids layer: n/a Depth of scum layer: We Dimensions of cesspool: n/a Materials of construction: We Indication of groundwater: n/a inflow(cesspool must be pumped as part of inspection) n/a Comments:(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) n/a PRIVY:_ (locate on site plan) Materials of construction: rda Dimensions: n/a Depth of solids: n/a Comments:(note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.) n/a (revised 0427/97) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 40 Hamden Circle Hyannis Lot 81 Kathleen Cessie 9/12197 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references, landmarks or benchmarks locate all wells within 100'(Locate where public water supply comes into house) qj 00 A �� tiG Pr 70 (revised 04/27/97) page 0 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) 40 Hamden Circle Hyannis Lot 81 Kathleen Cassie 9/12/97 Depth of groundwater 12 Please indicate all the methods used to determine High Groundwater Elevation: Obtained from design plans on record. Observation of Site(Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of Health Check FEMA Maps Check pumping records Check local excavators, installers x Use USGS Data Describe in your own words how you established the High Groundwater Elevation.(MUST be completed) LISGS Maps and Charts (revised 04/27/97) fiat'• 10 of 10 4v LOI AT10 SEWAGE PERMIT NO. l v VILLAGE Z� Y INSTA LLER'S NAME i ADDRESS 9 UI'LDE R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED � � � ,� � . � � �'1 � a �. 0 �_ �� JC � �_ le _� �� C�, � �o � `` I�o.. . :�t.�d....... F"Zs.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL Lj " ......OF... ... Appfiration for EliiposFal Marks Tilmitrurtion Prrutit Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at :� A J ...... Location-Ad "s . �-- or Lot No. ...... - ..: � ......... WOwner.............. .• 9........... = ... eAyddres W 1------------l..-4.: ��vF --------.- Installer Address d Type of Building Size Lot_AT46jrt..Sq. feet V Dwelling—No. of Bedrooms.......... ............................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of ersons....... a Other—Type g p ............. Showers ( ) — Cafeteria ( ) Otherfixture --V.....................----------------------------------------------- W Design Flow................r,�-----_-•------__-__gallons per person per gay. Total dai ow.._...... .. Ions. -----------1 WSeptic Tank—Liquid capacity` Qgallons Length........... Width...... .._ Diameter_-.--.__-__--.. Depth................ x Disposal Trench—N . ..................... Width.................... Total Length..........I...../`Total leaching area....................sq. ft. _ Seepage Pit No_______ ___________ Diameter........16._..... Depth below inlet... . ...... Total leaching area- .-�sq. ft. Z Other Distribution box (� Dosing tank y�,e, W Percolation Test Results Performed by..��4r........1 �,sdd ✓� .... Date... 11�/.... ... ...... Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ f=, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water. _/ .LI,:2� x Description of Soil ----:�' �^----------------- W UNature of Repairs or Alterations—Answer when applicable............................................................................................... ---------------------------------------------••---••. Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of iITI,L 5 of the State Sanitary Code—The undersignLfurther agre s not to place the system in operation until a Certificate of Compliance has be issued by the board o . _ Si ed ---- .............. .... Date Application Approved BY-_--•- ,�_ -- I�L-- Date 1 -- -_-_l `.7�' Application Disapproved for the following reasons:................... . ----....-•-----•--•.................................................... ............-- ..............•--------------•----------...--•---------------...-•---------------.•.......-----.........---•-•••-••••--•--••----••.----•--••----••---•--------•--•-•••--------•-----•••--•-•---......-- Date PermitNo......................................................... Issued-• �'' Date No..- -.. ( FEB.... V THE COMMONWEALTH OF MASSACHUSETTS i BOARD OF HEALTH ..........................................O F........----..........................-----------------•--.....-----•---•-............... App irat on for Uiipos al Works Tonitrnrtion Vermin'` Application is hereby; made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal . System at ; ^" s! Location-Ad dress or Lot No. gOwner s Address c a •---•v,'- -2 •""+�c- -•�---•-„F=- "L.. ... ..--- ......... ............................__sue ._ . . .v".'_i'!".:!.t"' .....'........... Installer �' Address Type of Building , . Size Lot:./,e�_.6.• ._Sq. feet . Dwelling—No. of Bedrooms_._......._ .__._Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Buff ing , � -�> No. of persons------- ----_•-_-.-.-- Showers ( ) — Cafeteria ( ) Otherfixture :----•-•-- --------••••---------•--------•-------•-••--••-.._..-- . ...................... W Design Flow.... gallons per person per �ay. Total daily. low........ r g -:_. ..:............. �-- �----------------dons. WSeptic Tank—Liquid capacity j..A gallons Length..... ...... Width...... 11...... Diameter---------------- Depth................ x Disposal Trench N . . ._.......... Width.................... Total Length.........4 'gotal leaching area....................sq. ft. Seepage Pit No. Diameter ....... Depth below inlet__. _... Total leaching area.. _sq. ft. Z Other Distribution box O Dosing tank ( ) a Percolation Test Results Performed by..A-!-� 4, .....6!.. '._. Date_._. " Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water------- --.--.-----._-. LL, Test Pit No. 2................minutes per inch Depth of Test Pit...............---- Depth to ground - = , D Description of Soil------------sue-- "" �`� � f '"� :..�s..� '�..�..y ..r�.-{-- ...........................' x .....--•------------•...... .. - _ - . :- ...................-•-••................................................................................................................................................................................ V Nature of Repairs or Alterations—Answer when applicable..........................::......__.._._...........___._......___...........__._.._._;........ --------••-•---------------------------------------•----•--•------------•--....-----•----------.....---•--......------------------..................--......-•••--------•------------...........----•- Agreement The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITHE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health Si ed .. .---------' - `� -+` ' — Dat Application Approved BY .....•---. :_:...-•-- ......................................... . Date APPlica�tion Disapproved for.the following re , a.' .....::..................................................................................................._................•._.._...-----.....__.............---._..__..... ......................... ;Date PermitNo......................................................... Issued-... .................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH OF.............frz ... wrrtifirtttr of Toutpliatta THIS W TO CERTIFY,,,.X, t the Individual Sewag Disposal System constructed ( ) or Repaired ( ) Y _,a { Installer le'i' at._.......�. , .......... f •. -----• has been installed in accordance with the provisions of TI& 5 1 The State Sanitary C �s described in the application for Disposal Works Construction Permit No..............6....................... dated------ -4°,l_`._/. ...................... THE ISSUANCE OF THIS CERTIFICATE SHALT.*NOT BE CONSTRUE® AS A GUARANTEE THAT THE SYSTEM WILL F CTION SATISFACTORY. DATE...... .. 7� -•- Inspector =.................................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ......OF.---... .1� . G No..............-�..... FEE... Disposal Works Too trnr#ion.. Permission,is hereby granted...... .., ._ to Constru r Rep# ( ) Indi uale age sposal System } at No.. ..... Street as shown on the application for Disposal Works Construction Per o..__._ /_/.y�....._ ated...e? 0 _.-.............. _.a-----•-----------------^ Board of Health DATE...............................................-----------------------=--------.- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS' ASSESSORS MAP: _ ..cf3—f .............. ._ _-_-___�._.__� __.._.___ �'`�� . TEST HOLE LOGS PARCEL; _.._._ ' • D/ �!-�L,/G t �G SO)L EVA�U TOR . '-1 .7 �r FLOOD ZONE• _----- — --- __ __ --._:.,.. ___ _ ; . WI TNESS:" ll — ► _ __ '� L,,— s i REFERENCE; �v. _. ..:.... DATE: FERCOLAT I QN RATE 1 1 � JW✓ oL . ..,. TH- I - TH-2 Al LOCATION MAP 2 3 _-- --- Put *Aq AAOO \ SEPT L C "SYSTEM DESIGNOt 71 FLOW ESTIMATE ` \ _. _ b \ BEDROOMS AT /U GAL/DAY/BEDROOM 21 GAUDAY _----� .. _'_'4 _ ! - :, �'1 .•- ----- \ ' U I \ - �,,'\ SEPT I C TANK l O / GAL/DAY x 2 DAYS GAL. -. /4�GALLON SEPTIC TANK �G�'l��l SOIL ABSORPTT SYSTEM 0 GA? I\qrjt,TtK jbiL5 W ( \ DAB T � S 1 DE ARC ` B. 7 12 rid • 7_X 9 � , A 00,000, ol BOTTOM AREA: /D.$ 3 , - lo -�. \ of9 J SEPT:I C SYSTEM SECTION NI list v a ^, r I / ,35,od 0 r b w ,' . GALTV it TAB SEPTIC 'TANK t4 ` .. — , o SITE AND SEWAGEPLAN LOCATION : �' .,.? ;," PREPARED FOR ' SCALE DAV i D B . MASON DATE: - 16 DBC ENVIRONMEN`fAL DESIGNS EAST SANDWICH MA DATE HEALTH AGENT i , ( 508 ) 833-2177 r �� `'� FtaI+SH G�PADL-•l4x5 � �tNtSM G�r4�� 1MA;`N (s1F'�(i�L°f -�__.._....._._ OvE1t.T/F NK � -LA" OVER ! lr sr 13 X Q To pp o f!'a y Nt>. 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