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Home My WebLink About0073 LILLIAN DRIVE - Health 73 Gillian Drive. -_ =-- Hyannis P . �c -n,= 24'8 196 It J o it is i i a w ° { o Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 73 Lillian Drive Property Address , Anne Mayo Owner Owner's Name information is Hyannis Ma 02601 9-10-2020 c required for every H y ' page. City/Town State Zip Code Date of Inspection r. Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation Company Name 374 Route 130 Alf Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 Telephone Number License Number t 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 9-10-2020 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. i ****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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 9-10-2020 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Ins pection ection Summary: Check A B C D or E always complete II of Section D A) System.Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The 2 cesspools and overflow leach pit were in passing condition at time of inspection. Main cesspool was pumped as required for inspection. 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-.3/13 Title 5 Official Inspection Forth: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 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every y H annis Ma 02601 9-10-2020 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): F ❑ 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 9-10-2020 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: I 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 ondin of effluent to the surface of the round or surface waters P 9 9 due to an overloaded or clogged SAS or cesspool 99 o P 0 ❑ ® 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 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is Hyannis Ma 02601 9-10-2020 required for every H y 'i 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•3113 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 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 9-10-2020 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): No design plans Number of bedrooms(Actual) 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): NA t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 9-10-2020 page. City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail 2018-no record 2020-45,628gallons Sump pump? ❑ Yes ® No Last date of occupancy: CurrentDate Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on 310 CMR 15.203): canons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Lillian Drive Property Address Anne Mayo ' Owner Owner's Name information is required for every Hyannis Ma 02601 9-10-2020 page. Cityfrown 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: Pumper driver Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000gallons How was quantity pumped determined? Pump station slip Reason for pumping: Required for inspection. 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): Cesspool, overflow cesspool overflow, leach pit - t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments _ yy 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 9-10-2020 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: Pit added 1992 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ® other(explain): Distance from private water supply well or suction line: Town feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: NA 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: Sludge depth: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis annis Ma 02601 9-10-2020 page. Cityrrown 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 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 How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap (locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑fibefglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis annis Ma 02601 9-10-2020 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: NA 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.): f *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No i t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 l Commonwealth of Massachusetts x Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 9-10-2020 page. Citylrown 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 NA Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): NA * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments y 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 9-10-2020 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: (1) 6'x8' ❑ 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 was in working order at time of inspection with no sign of hydraulic failure. Leaching was dry when viewed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Cesspool, cesspool, pit in series Depth—top of liquid to inlet invert 6 Depth of solids layer Depth of scum layer 1 Dimensions of cesspool 6'x8' Materials of construction blocks Indication of groundwater inflow ❑ Yes ® No t5ins-3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 9-10-2020 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: NA Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): 7 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 73 Lillian Drive Property Address II! Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 9-10-2020 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 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 Driveway Al-31' 131-47' A2-45' 132-28' A3.83' 133-22' A REAR a cesspool cesspool pit t5ins•3/13 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 73 Lillian Drive Property Address Anne Mayo Owner' Owner's Name information is required for every Hyannis Ma 02601 9-10-2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water l ® Check cellar ® Shallow wells Estimated depth to high ground water: No GW @ 20'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: COC dated 6-9-92 Date t ❑ 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: Info on file with BOH. 1 II r Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 ll r r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments y�< 73 Lillian Drive M v. Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 9-10-2�020 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 a�8 196 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 73 Lillian Drive Property Address Anne Mayo ' Owner Owner's Name �j information is required for every Hyannis ✓ Ma 02601 3-30-18 =f page. City/Town State Zip Code Date of Inspection j.,;s Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Brett Hickey use the return Name of Inspector key. B&B Excavation raa Company Name 374 Route 130 Company Address Sandwich Ma 02563 City/Town State Zip Code (508)477-0653 S113747 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 3-30-18 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection.does not address how the system will perform in the future under the same or different conditions of use. i t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Go��{VS Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 3-30-18 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: ® 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 2 cesspools and overflow leach pit were in passing condition at time of inspection. Main cesspool was pumped as required for inspection and the second cesspool in series was dry. 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. i 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 3-30-18 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/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): e ❑ 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 3-30-18 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: i 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/day flow t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not.for Voluntary Assessments 73 Lillian Drive 1M I Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 3-30-18 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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 aisurface 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 i ❑ ❑ 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. l5ins•3/13 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 �M 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 3-30-18 page. Cityfrown State Zip Code Date of Inspection C. Checklist i 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? - i ® ❑ Was the site inspected for signs of break out? 'i ® ❑ 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): No design plans Number of bedrooms(Actual) 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): NA t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 3-30-18 page. CityFrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 1 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 I Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage d See below 9 ( Y 9 (gP ))� Detail: 2016-22,440gallons 2017-31,416gallons Sump pump? ❑ Yes ® No Last date'of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: NA Design flow(based on.310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 i Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 3-30-18 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: Pumper driver Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1000 gallons How was quantity pumped determined? Pump station slip Reason for pumping: Required for inspection. 1. 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): Cesspool, overflow cesspool overflow, leach pit t5ins•3/13 Title 5 Official Inspection Farm.Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 3-30-18 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Pit added 1992 Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan).- Depth below grade: 4 feet Material of construction: ❑ cast iron ® 40 PVC ® other(explain): Distance from private water'supply well or suction line. Town feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: NA feet Material of construction: r ® 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.- Sludge depth: (Sins•3113 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 M 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 3-30-18 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 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 — How were dimensions determined? Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Grease Trap(locate on site plan): Depth below grade: NA feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: — Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 3-30-18 _ 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: NA Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: — Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: - Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 f Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 3-30-18 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 NA 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.): I I 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.): NA ' If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a° 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 3-30-18 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: (1) 6'x8' ❑ 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 was in working order at time of inspection with no sign of hydraulic failure. Leaching was dry when viewed. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Cesspool, cesspool, pit in series Depth —top of liquid to inlet invert 6 Depth of solids layer 8 Depth of scum layer 2 Dimensions of cesspool 6'x8' Materials of construction blocks Indication of groundwater inflow ❑ Yes ® No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 3-30-18 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: NA Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)-. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ,^M 73 Lillian Drive Property Address Anne Mayo. Owner Owner's Name . information is required for every Hyannis Ma 02601 3-30-18 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) 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 Driveway Al-31' B1-47' A2-45' 82-28' A3-83' B3-22' q REAR B 0 0 cesspool cesspool pit t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts y Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is y required for every Hyannis Ma 02601 3-30-18 page. CityrFown 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: GW @ 20' feeee t 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: COC dated 6-9-92 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: Info on file with BOH. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 • Commonwealth of Massachusetts H W Title 5 Official Insp ection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 73 Lillian Drive Property Address Anne Mayo Owner Owner's Name information is required for every Hyannis Ma 02601 3-30-18 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 I Commonwealth of Massachusetts Title.5 Official Inspection Form s Subsurface Sewage Disposal System Form Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for every Hy annis/CeRtewiUe, MA 02632 06/12'/12 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 A. General Information filling out forms on the computer, Z�o use only the tab 1. inspector: key to move your cursor-do not Michael Kellett use the return Name of Inspector key. Aardvark Environmental Inspections VQ Company Name PO Box 896 Company Address East Dennis MA 02641 City/Town State Zip Code 508-385-7608 S13742 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal.system at this address:aAd that the= information reported below is true,accurate and complete as of the time of the inspe-ction.The inspecti6 was performed based on my training and experience in the proper function and maintenance of bit site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340sof . ' Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails. C-j . ❑ Needs Further Evaluation by the Local'Approving Authority ; 4- i!% 7 06/14/12 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP-.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•11/10 Title 5 Official Inspection FormVibsurface ewage Disposal System•Page 1 of 17 f Commonwealth of'Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for every Hy annis/Centerville MA 02632 06/12/12 page. Citylrown State Zip Code Date of Inspection B. Certification (cone.) Inspection Summary:Check A,B,C,D or E/always complete all of Section D " A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 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):. I5ins•11/10 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 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for every Hyannis/Centerville MA 02632 06/12/12 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) I B) System Conditionally Passes (cont.): i ❑ 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): I ❑ broken pipe(s)are replaced, ❑ Y ❑ N. ❑ ND(Explain below): I ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): 4 ❑ 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): j 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 mannerwhich will protect public health, safety and the environment: Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh Lj}nS•I'u i u �-.�e 5"'-1-ta1 fnsps&ami Fugcif:S&S'LITS^.ce a U.-POW,Sy�LeM•Page 3 C'17 Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System form Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for every Hyannis/Centerville MA 02632 06/12/12. page. City/Town 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.ofa 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: I **This system passes ifthe 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_ Il 3. Other: j i r I i D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspection: Yes No i ❑ ® 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 ❑ M Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 at 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form & Subsurface Sewage Disposal System Form Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for every Hy annis/Centerville MA 02632 06/12/12 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No El ® 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 ar 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 necessaryto 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. i 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 Il'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 Deparlment_ t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection: Form. Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for every Hy an nislCenterville MA 02632 06/12/12 page. Cityrrown state Zip Code Date of Inspection C. Checklist Check if the following have been done.You.must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner,occupant,or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?,(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components,excluding the SAS,located on site? ® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid,depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information.For example,a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)]; D. System Information I Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal-System Form Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for every Hy annis/Centerville MA 02632 06/12/12 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings,if available (last 2 years usage(gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: D rerent CommerciaUlndustrial Flow Conditions: Type of Establishment: - Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft.,etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank.present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings,if available: t5ins-11/10 Title 5Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for every Hy annis/Centerville MA 02632 06/12/ 2. page. Cityfrown State Zip Code Date of Inspection D. System Information (cunt.) 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 0 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 VA system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): i t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for every Hy annis/Centerville MA 02632 06/12/12 page. Cityfrown State Zip Code Date of Inspection D. System Information: (cont) Approximate age of all components,date installed(if known)and source of information: 06/09/92 for precast pit per BOH Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 4.0 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.): Septic Tank(locate on site plan): Depth below grade: 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: Sludge depth: t5ins•11/10 Title 6 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Farris s, Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for every Hyannis/Centerville MA 02632 06/12/12 page. Cdy/Town state Zip Code Date of inspection D. System Information (cont.) Septic Tank(cost.) Distance from top of sludge to bottom of outlet tee or baffle 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 How were dimensions determined? Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete El metal 0 fiberglass ❑ polyethylene F-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•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form { s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Lillian Drive Property Address. Michael Donelly Owner Owner's Name information is required for every Hy annis/Centerville MA 02632 06/12/12 page. Cityfrown 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.): i 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): k Dimensions: Capacity: gallons f Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑, Yes ❑ No Date of last pumping: Date_ i Comments(condition of alarm and float switches,etc.): i i Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Trlte 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for very y H annis/Centerville MA 02632 06/12/1.2 e page. City/Town State Zip Code Date of Inspection D. System Information (cunt.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): Pump Chamber(locate on site plan): Pumps in working order: ❑! Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber,condition of pumps and appurtenances, etc.): Soil Absorption.System(SAS)(locate on site plan,excavation not:required): If SAS not located,explain why: t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for every Hyannis/Centerville MA 02632. 06/12/12 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: Ej leaching pits number:. i ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number,.length:. ❑ leaching fields number,dimensions: ® overflow cesspool number: 2 ❑ 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.): This system has a 6'x6'precast pit surrounded three feet of stone and a5'x5'drywell block pit neither of which show any significant staining. Cesspools(cesspool must be_.pumped as;part of inspection) (locate on site-plan): Number and configuration 2 intee form Depth—top of liquid to inlet invert 48" 1 Depth of solids layer Depth of scum layer 1 Dimensions of cesspool 5'x5' Materials of construction drywell block Indication of groundwater inflow ❑ Yes ® No t5ins-11/10 TrUe 5 Official Inspection Form:Subsurtace Sewage Disposal System Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for every Hy annis/Centerville MA 02632 06/12/12 page. Cityfrown 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.): The cesspool was in good shape with a stain line well below the outlet inverts both of which had PVC tees which had no stainging on them. 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.): LtMn. /l0 Trde5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commontweakh of Massachusegs Title 6 OfficialInspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name rnforntafion Wred for every y req�red fo H annis/Centerville MA 02632 06/12112 page. cftyrrown State Zip Code Date of lnspedion D. System Information (font-) 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 budding.Check one of the boxes below. .hand-sketch in the area below ❑ drawing athac hed separately %ins 11110 Till 5 Offetal Irmpe[tlon Fenn:SUbsudece 6 Disposal System•Page t5 of t7 Commonwealth of Massachusetts Title 5 official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for every Hy annis/Centerville MA 02632 06/12/12 page. Cityrrown state Zip Code Date of Inspection D. System Information (coat.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 20.0 feet Please indicate all methods used to determine the high ground'water elevation: ❑ Obtained from system design plans on record If checked,date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health explain: ❑ Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS maps show an elevation of over 20.0 feet I Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 73 Lillian Drive Property Address Michael Donelly Owner Owner's Name information is required for every Hyannis/Centerville MA 02632 06/12/12 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 4 f t5ins-11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 ' � TOWN OF BARNSTABLE SEWAGE# VII.,L=AGE J ASSESSOR'S MAP& LOTa INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY OO V fI LEACHING FACILITY: (type)_�(. (size) NO.OF BEDROOMS BUILDER OR OWNER PERMIT—DA'M: 3bh9 COMPLIANCE DATE: Separation Distance Between the: j Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ! Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) ! Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by � � 7:73 ss � l c) Z � 3 -�3 83' TOWN OF BARNSTABLE • r 'LOCATION -7 j �,lTg�) 1I1�-P SEWAGE # VILLAGE 4AM C- ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. L. SEPTIC TANK CAPACITY eidS7�— � / I LEACHING FACILITY:(type) & ems% 0'' IT (size) NO. OF BEDROOMS 7 PRIVATE WELL OR JTUEWA R�� BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: `�- VARIANCE GRANTED: Yes No (�, )1 'b4 wwnn 11 � i rZ A Fus........3.0...... THE COMMONWEALTH OF MASSACHUSETTS APPROVE? BOAR® OF HEALTH r�c0" '°"0Q� TOWN OF BARNSTABLE Apli irativit for Diipusal Works Towitrnrtinn ramit Application is hereby made for a Permit to Construct ( ) or Repair ( A-<an Individual Sewage Disposal System at: ...:.....---•-•-..7_3...�... �.1t31�i -�? ' ................... ............. ...................................................---- y�Locatio Address r or Lot No. W Owner �r .................................... dartys ( Installer Address U- Type of Building Size Lot............................Sq. feet Dwelling=No. of Bedrooms___' ..................................Expansion Attic ( ) Garbage Grinder ( ) aOther Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtuu ----------------•---------------------------------•---I-----------...-------------------------------------••• .•-----------..........------------ W Design Flow............ ... . ....._._...._.._gallons per person per day. Total daily flow_._.. .. --.._.........................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.............___.... Total Length.................... Total leaching area.....................sq. ft. Seepage Pit No--------j------------ Diameter......!.& Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ �4 Test Pit No. 1.....:..........minutes per inch Depth of Test Pit.................... Depth to ground water----_-_______-__---_-__- PC4 Test Pit No. 2................minutes per inch Depth of.Test Pit---:................ Depth to ground water........................ -•-•-------•----------------•----.........-•---••--•-----------•----------------•------•'..... ......................................................... 0 Description of Soil......................................................................................................................... -------- ................ ............ U ---••......................................................•------••-....------------•--'-.....------....-----------------------•------..-------------------------- UW --------------------------------------------------------------------------------------------------••--------- .. ....... p Nature of Repair or Alterations—Answer when applicable___ ------ . 9t3 .................... ----------------------------------------------- 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 Compliance has be issued b the boa of g D� Application Approved By ----------------- ----t V... ` ........... - dP .. . Application Disapproved for the following reasons- ------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------_...-------- -----.............................._.:. ---------------------------'-"------------ --'-------- Date PermitNo. ......... ..-... 0................. Issued .................................................................... Date e,� No.-1-12.-..JW Fps..... ..... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH , TOWN OF BARNSTABLE •�—� —�— 9az Appliration for UWpaiin1 Works Tonstrtirfiun Famit -- Application is hereby made for a Permit to Construct ( ) or Repair ( ,r)'an Individual Sewage Disposal System at: Location--Address or Lot No. ��, u e l� ................ ........................................................................._..... Owner _ C. l 1 !� -_ f 1 N ? t 1 �✓ O?C Address / -..._..A. 1` !")/r Installer y Address UType of Building Size Lot..... ......... .........Sq. feet �-t Dwelling—No. of Bedrooms...._``.....................................Expansion Attic ( ) Garbage Grinder ( ) Other—T e of Building No. of persons............................ Showers a YP g ---•-----•-----•------------ P ( )--- Cafeteria ( ) dOther fixtures .----•-•---••-••---•----------••-•••---------•--•--•---••--•--•-•--•-•------•-----•-•---••--••••......---••-••••-_.. ......_... W Design Flow............ .. ....................gallons per person per day. Total daily flow----- ...................................gallons. WSeptic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft. , Seepage Pit No--------- Diameter......LZ)._.... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by---•••......--•-------••......•-- Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit._____._........_._. Depth to ground water........................ �r, Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ 9 ••••--••--•--•-•••....-•--•-•--••---•••------•••••••--••---•-•••----•-....--•-•-----•...................................•-••••••----•---...-••••-•-•---....•. 0 ' . Description of Soil.......................... (xj ......•--••-----•------------------••--•--•---.......---•-••------•----------------•--------•----••--------.................................................. W VNature of Repairs or Alterations—Answer when applicable__--- _`�__4Y......1406_�t .etl n ..................... Agreement: 71 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 Compliance has been issued by the board of health., rr� -Signed . .-. ...........................� . .... ... ." .�..... c..� ...-- -- Date Application Approved $y .......... - ?-tom r�.,, -, ......... ........ - -- ------4-.)- A �s ... ... .' _ - \1Date pplication Disapproved for the following reasons: ................... ..... ............................ .................. .. ----------------------------------------------------------------------------- - -------- ------------ ------------------ -- -----------------=.............................- :.... Date Permit No. .......... ` ............. Issued ......... Date r THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Cler#ifi ate of Compliance THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired by.......................................!_`- /:4 P..................................... "fil S >=i I _-.- .... ............................... ---'- -.Insmller at ..........................................-� � f�'' � ........ �v' �- , h.-- =.`�1-F:..,v.!.4------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in T the application for Disposal Works Construction Permit No. ........ .........t?_0...... dated ......----------------------------------------- THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE .............................................. Inspector .--------------------- .....�� J ......... ---- ---------- ---- ---------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE,, FEE.. ................... Dispooal Work.5 T11notrudion antic Permissionis hereby granted.......-!�C•- ..........................................l C _,.............................................................. to Construct ( ) or Repair (�) an Individual Sewage Disposal System!! t •,, _ -5 ...... ..? 1 ,- t ry at No. ---•-•----•---...-•-•------•-..........�....•--••----•---••••••----------------•---•-••--••-•-•••-......--._...-----------------•--•--•-•--......... Street �� '/� as shown on the application for Disposal Works Construction Permit No... ..........•._ Dated.......................................... -------------•-•-----•-------------------------•- /- q Board of Health DATE-----•------•----•-•--......v`../....-. ... FORM 36508 HOBBS&WARREN,INC.,PUBLISHERS i o nil •: w o a N v:G I 4e Town of Barnstable co Health Department 367 Main Street, Hyannis, MA 02601 rwa err • Office 508-790-6265 Thomas A. McKean FAX 508-775-3344 Director of Public Health November 30, 1990 0a� Mr. Martin Powell 73 Lillian Drive Hyannis MA 02601 NOTICE TO ABATE VIOLATIONS OF 105 CMR 410.000 STATE SANITARY CODE II. MINIMUM STANDARDS OF FITNESS FOR HUMAN HABITATION AND THE TOWN OF BARNSTABLE BOARD OFHEALTH S NUISANCE CONTROL REGULATION NUMBER ONE The property owned by you located 73 L-i-1-l-ian—Drive1,,Hyannis;? listed as parcel 196 on Assessors Map-2'4"8 was inspected on November 30, 1990 by Donna Miorandip Health Inspector for the Town of Barnstable, because of • a complaint. The following violations of the Nuisance Control Regulation Number One and the State Sanitary Code II were observed: 105 CMR 410. 602: Piles of brush, branches, and wo d on the ground located at the empty lot located across from 84 Lillian Drive, Hyannis) . You are directed to remove these items within four (4) days of receipt of this notice. You may request a hearing if written - petition requesting same is received by the Board of Health within seven (7) days after the date order is received. However, these violations must be corrected regardless of any request for a hearing. Please be advised that failure to comply with an order could result in a fine of not more than $1400.00. Each separate day' s failure to comply with an order shall constitute a, separate violation. You are also subject to a $25.00 ticket. Tickets will be issued , daily until the violations are corrected. PER ORDER OF E BOARD OF HEALTH Whd�sA. McKean Director of Public Health TM:cst / t - ;' ,•, ;. ': t..� t 1��,..r-. Sz 3 ^irk x t� � f t� t .';�s. fa - q' r • SENDER: Complete Items 1 and 2 when a, t t ! des + complete ,� 3 and 4. Put your address In the"RETURN TO" Space on the revers aide.Failure.eo 30 this will prevent this card from being returned to you. he etur receipt fee will rovide ou the name of the person delivered to and the date of deliver For a t one ees the Tollowing services are available.Conou pos mas er or fees and check ox es for additional servicelsl requested. t" 1. ❑ Show to whomdeliveredi( date �nd,addresaee's addreas.s,12 , ❑, � ►SeJ livery%p ,,, 3i Article Addressed to: ., rt,j;, 4 Article.Number k',�5P"165 534' 417 " Martin Powell Type of ServlCe XtY*^��' U Registered 4 ,.;❑ Insuted: � 73 .Lillian Drive � �a � �. ❑Cerdf�ed xi'❑ COD TIjrarmis MA 0260Y x �xi � ❑ Express Mail ❑ P. r Mo Receipt « �.� , or Merchandise A�iways obtalp signature of addressee .X +xX+ r * or agent and DATE DELIVERED. 5. Signature—Address t . °t ,��}yy 8 a Addresse-eYA,Address, (ONLY ;,� �., 4 F �4. f+CE paid x 3+4 8..Signature =Agent # ,. +!a a�'.4 br9 ?# X e rk' wg'jf "i is?«sl. t On l��jy.}+i¢yK4pp � $ 7. Date of Dalive f s PS Form 3811,Niar,11988, ;, U.8.QP 0.,1988 t212F8863 DOMESTIC RETURN RECEIPT . Y