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0482 LINCOLN ROAD EXTENSION - Health
482 LINCOLN ROAD EXT.,HYANNIS A= 2.72 067 al j J TOWN vF BARNSTABLE e'?LOCATIONS°C/l��/� �' SEWAGE # ' VILLAGES/����f -�ZePW/ ASSESSOR'S MAP & LOT INSTALLER'S NAME& PHONE NO. SEYnC TANK CAPACITY LEACHING FACILITY: (type)`?I kk f �� (size) NO. OF BEDROOMS 7 BUILDER OR OW`NTR dJ�Q/lL/0-� 40 PERMITDATE: COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands e t within 300 feet of aching / il; Feet Furnished by ta. � JQ a' t° T LOCATION SEWAG0 PERMIT NO. �� 6 VILLAGE a�a --00 INS A LLER'S NAME i ADDRESS 8 U I L 0 E R OR OWNER DATE PERMIT ISSUED DATE COMPl1ANCE ISSUEO������ CG1 1 CVO r� 1 Nj................A....... a, l Fss.. ®................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH '�, �.1�.�✓ ...........OF....... Applira#iou for Di-gVos al lRurks Tomittrudivit thrmit Application is hereby made for a Permit to Construct 044 or Repair ( ) an Individual Sewage Disposal stem at: Location-Address or Lot No. iMRN..T u?4il,txt .. + __.G°F► .._.5� .......................... ....................................... �9.. ........... I7�----------------------- Owner Address Installer Address T d Type of Building Size Lot__/_7t._S'.-&.0......Sq. feet V Dwelling—No. of Bedrooms.............! ------------------------Expansion Attic ( ) Garbage Grinder ( ) pa-, Other—Type of Building --______-_-_•-_-__-______- No. of persons____________________________ Showers ( ) — Cafeteria ( ) P4 Other fixtures ------.••••---•---•---•-------•---------.._...._....••••• -••--••-••-••••-•••---...--•--••---.--------- W Design Flow.................�v�.r ..._._________gallons per person per day. Total daily flow___........ P................. WSeptic Tank—Liquid capacity_'@__gallons Length_____9_°_____ Width......-__•_�__ Diameter________________ Depth..... x Disposal Trench—No..................... Width_------------------ Total Length..__.__......je.. Total leaching area______-_--._--------sq. ft. Seepage Pit No.____.._1........... Diameter......./.U! 4 .... -_- 4-8--_... Depth below inlet_.34. -. Total leaching areaJ. sq. ft. Z Other Distribution box ()o Dosing tank ( ) `-' Percolation Test Results Performed by-----�'���e...�-�� ----- .... Date--9-®-3.- - __f..------ aTest Pit No. I----I---------minutes per inch Depth of Test Pit---14_1...... Depth to ground w terA107- ��U_ Gz, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to,ground wa er-._.--_____._._..-_____. Ra' -----------------•••----•••-••--....•--••••......----••----- O Description of Soil--- - Eft,-•4.Oem.., cJ, <7 t j .......... --1-.Ai. � � ���$------------------------- U f�'-•--�--�----s���-g---------•------------------- ------------------------------------------------------------------•-•---••------------...-- W !/ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable------------------------------------------------------------------------------------------------ -------------------•----....-----------------------�n---------------------------------•••-•-••-•••••••-••••-•-•••---••--..:...•---•...-•••••......-•------•••-......•••••••••••......-••••------•.....•... Agreement: �1' i The undersigned agrees to�installof d`escribe�dividual Sewage Disposal System in accordance with the provisions of i i:I p of the State Sanitary Code— The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been A sued by + and of health. u I Sied -, .. .--• -- --- ................... Date Application Approved By--••• f = --•--•--------------- ...1A.':.....'_7 . - --------- Date Application Disapproved for the following reasons:............................................................................................................... -----•-----------------------•---•-------•---•----------------------------•------•--...-•--••----------------------------------------------------------------------------------------------------....._. Date PermitNo......................................................... Issued....................................................... Date I - No...................... FEi3.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............ .. ..... ne.. ................... 4��J.........OF.............. Appliration for Disposal Works Tonstrurtivia j1prulit "Application is hereby made for a Permit to Construct (>4) or Repair an Individual Sewage Disposal ystem at: 42 JJ . .... ..... ................ ..!;;� - Location-Address or Lot No. .................. ................... . ....4..................... ....................'-Z�......................Owner Address ...................:a............................................................................. ................. ................................................. Installer Address — Type of Building- Size Lot.17. 15_0.0......Sq. feet — - r-- Dwelling—No. of Bedrooms...............9.........................Expansion Attic Garbage Grinder ( ) Other—Type of Building ............................. No. of persons............................ Showers Cafeteria ( ) 114 Other fixtures ....................................................................................................................................................... Design Flow................... ci ..............gallons per person per day. Total dail flow........... 0.................gallons. 1:4 Septic Tank iquid*capacity/004..gallons Length...... ..... Width.. Diameter................ Depth.....4....... Disposal Trench—No..................... Width..................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........I........... Diameter....:./.O!.... Depth below Total leaching area...]. .,8.sq. ft. z Other Disiributioril box Dosing tank Percolation Test Results Performed by.....OA?p 4Ge ........ 1-4 Test Pit No. I.... .........i minutesperinch Depth of Test Pit.../.Z......... Depth to ground waterMAO-r..... ti 49'�-4fatejM0 44 Test Pit, No. 2................minutes per inch Depth of Test Pit.................... w i 4=QUAJ........ Depth to ground ........................ ...............................................................................I............................................................................... 0 Description of ".A .. ......................... ............................................................................................................................ ........................................................................................................................................................................................................ U Nature of Repairs'or Alterations—Answer when applicable........................:...I.................................................................. ........................................................................................................................................................................................ Agreement: The*undersigned agr�a�f8o3reides:cri�bed�dividtiaI 'Sewage Disposal System in accordance with f" the of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued1by the board of health.. Vile, ........ ..... ...................... Application Approved By.......;V;00.00.. .......... ........................................ Date Application Disapproved for the followind '_"�' reasons:.............................................................................................................. ........................................ ..........................Y...................................................................................................... ............................ Date PermitNo............�,! ...................................... Issued....................................................... Date JHE OMMONWEALTH OF MASSACHUSETTS BOARD OF HEALT ...................1 ...OF...................... . (Urtif iratr of Toutpliattrr THIS IS TO CERTIFY �w That the Individual Sewage Disposal System constructed or Repaired .............. ....... .... ......by..........-. V. .............. . .. . ... al ................................................................ .......... has been installed in accordance with the provisions of TITLE 5 of The State Sanitary C." Iieso4W in the application4di Disposal Works Cons'truction Permit No................... ........I............ dated......--.-.....::...............................(V . ir . THE'ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEhCWILL FUNCTIO" SATISFACTORY. DATE............... .. . .. ................. ........ Inspector....j�wj..4,..... . ..... ................ ................... THE COMMONWEALTH OF MASSACHUSETTS BOARD, oF,0HqALTH ........................... ............ ........... ....OF......... ............................................. No........................ . FEE........................ Disposal Vorks 6janstrudian "immit Permiss* ...........)Tn.Vhereby gran .. ...... . . ......... toConst ep4V n •S at No....................................1P .... .......4 .........................................ZV4................................... ............... ...... Slree 4 as shown on the application for Disposal Works Construction Pe 0..... ed........ .......... ...... ......................................... ... ..... ......... ].Board of Health DATE.----....31 .... ............................. FORM 1255 HOBE3S'& WARREN, INC., PUBLISHERS r 1 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form.- Not for Voluntary Assessments 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is Hyannis MA 02601 , required for every y page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms (� on the computer, �q use only the tab 1. Inspector'. key to move your cursor-do not Forrester L. Quinn use the return Name of Inspector key- F.L. Quinn r� Company Name P.O., Box 514 Company Address Orleans MA 02653 City/Town State Zip Code 508-255-4544 1596 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 r, " ❑ Needs Further Evaluation by the Local Approving Authority In�Si nature Date — --- .Aj The system inspector shall submit a copy of this inspection report to the Approving Authority3(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 ff al Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts d Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is required for everyannis MA 02601 - 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: 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•11/10 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 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is Hyannis MA__ 02601 t nn required for every y _ � �' �X page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health., safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 482 Lincoln Road Extension _ Property Address Theresa Mansfield Owner Owner's Name information is Hyannis MA 02601 required for every 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 of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: ** This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ �/ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ R/ Liquid depth in cesspool is less than 6" below invert or available volume is less than 'Y2 day flow l5ins•11/10 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 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is required for every Hyannis MA 02601S page. City/Town State Zip Code Date of Inspection B. Certification (cost.) Yes No ❑ [/ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ I 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. ❑ D� Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ 0?"' 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•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 �., 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is required for every Hyannis MA 02601 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: Y,.ees/ No L�( ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ L✓1 Were any of the system components pumped out in the previous two weeks? L ❑ Has the system received normal flows in the previous two week period? ❑ Rr Have large volumes of water been introduced to the system recently or as part of this inspection? 2 ❑ Were as built plans of the system obtained and examined? (If they were not / available note as N/A) 0 ❑ Was the facility or dwelling inspected for signs of sewage back up? C.VI ❑ Was the site inspected for signs of break out? L✓J ❑ 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: I� ❑ Existing information. For example, a plan at the Board of Health. d ❑ 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): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 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 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is required for every Hyannis MA 02601 — f page. City/Town State Zip Code Date of Inspection D. System Information Description: /0,0Cl f,411®.tj �nr it i ,Z -�05( — ,,S/�-s 10 Number of current residents: Does residence have a garbage grinder? ❑ Yes ['r' No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes P]r No Laundry system inspected? ElYes E�J No Seasonal use? ❑ Yes Z�No Water meter readings, if available (last 2 years usage (gpd)): ®l© ��,3 Detail: V%!y.eiC'l Sump pump? ❑ Yes P" No Last date of occupancy: Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft.; etc.): — Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: — t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is required for every Hyannis MA 02601 9 page. CityrTown 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: > ( N Was system pumped as part of the inspection? [✓ Yes ❑ No If yes, volume pumped: ( O� 9,4Llo,,� + — gallons How was quantity pumped determined? �('A 2,1- L�1•u'7j�,f W„/G�..v Reason for pumping: &04VLt Type of System: Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•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 ° M 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is required for every Hyannis MA 02601 9 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: �'y_sT-,-"o'l 1 iySTlgl (,J 19,�0 L Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): Depth below grade: y S feet Material of construction: Eq cast iron Q 40 PVC ❑ other(explain): — - Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.):: t1 Pf C I ry 100 �'t3 l,L_ ;.�� e✓E/!;%( 6,,-yd i F,(J z/ Septic Tank(locate on site plan).- Depth below grade: feet do Material of construction: Q 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: Get �►((oiJ Sludge depth: f - t5ins•11/10 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 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is MA 02601 required for every Hyannis_y 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 e, — / 6i Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle i How were dimensions determined? _Qyine Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): t 15��JFF�r` ins eaCt C.`?,W `7,�hJ O�JrdL! T1-76; ,Z4l�i,foa✓E7 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 15ins•11/10 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 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is MA_ 02601 _ 77 required for every Hyannis_Y _.— _� n page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: — -- Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: -- Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: — Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is ; required for every Hyannis MA 02601 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 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.): )VO /leffb- )4e /n0 OIL- ©cT 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•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal.System•Page 12 of 17 r Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is required for every Hyannis MA 02601 - page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: l [' leaching pits number: ❑ leaching chambers number: ❑ Teaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: — ❑ innovative/alternative system Type/name of technology: — — Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): A10 jic,z,S Or rAi l0 r4-1 VDjgA /00 4�,19M, Sc011 - /V v &�t' s.S 7,1 i 0,1a 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 15ins•11/10 Title 5 Official Inspection Forms 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 482 Lincoln Road Extension _ Property Address Theresa Mansfield Owner Owner's Name information is required Hyannis MA 02601 required for every � 9 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: — Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): l5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 I Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ;M 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is required for every Hyannis MA_ 02601 C) -13-u 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 q �` i � 6 rc ! i`I-to� �-,)0 L v t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is H annis MA_ 02601 Q required for every _y --, page- City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: ` 9 feet ti1CJ GtI, TC L %k�sJ1 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: 'I 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: /2s7 ife% /,v n' e y r,,% F-i �2 . 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 482 Lincoln Road Extension Property Address Theresa Mansfield Owner Owner's Name information is required for every Hyannis MA 02601 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist E 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 ET"Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 DATE:6/15/98 PROPERTY ADDRESS: -4.82 1Jincoln' Road -Ext. Hyannis,Mass. 02601 On the above date, I Inspected the septic system at the above address. This system consists of the following: 1 . 1 -1000 gallon septic tank. 2 . 1 -Distribution box. „ 3 . 1 -1000. gallon precast leaching pit. eased bn my lna x3ction, I certify the following conditions: 4 . This is a title five septic system;" �(" 98 Code ) 5 . The septic system is- in proper working order at the present time. 6 ., This system is designed for a three bedroom house. 7 . The present house now has four bedrooms. Liquid . level- in the leaching pit is 16" below the invert pipe. 8 . The system is not designed to handle a four bedroom house. 51GNATURYF: Name -J_P Macomber Jr... i 9 -- g 70 Company._J. P_Macomber & Son•_Inc A Address __R,a_x_gi______I_ _ JUN 2 6 1998 Centerville LMass__02632 ' TOWN OF BARNSTABLE HEATLH DEPT. Phone: ---50.8---77..5_3338_____-- THIS CERTIFICATION DOES NOT CONSTITUTE A GUARANTY OR WARRANTY JOSEPH P. MACOMBER & SON, INC. Tank&-Cesspool&-Leachflelds . Pumped & Instilled Town Sewer Connections P.O. Box 66' Centerville, MA 02632-0066 775-3338 775-6412 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS U9, DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON, MA 02108 617.292.5500 WlLL1AM F.WELD TRUDY COX! Governor Sccretar ARGEO PAUL CELLUCCI DAVID B.STRUH Lt.Govcmor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissions PART A CERTIFICATION Property Address: 482 Lincoln Road Ext H annis Helen Tufts p ny � y Address of Owner:C/0 Sharon Tufts Date of Inspection: 6/1 5/98 Mass . (If different) 450 Square Rigger Name of Inspector: ber Jr. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)Lane Hyannis Company Name: J.P.Macomber & Son Inc Mass. 02601 Mailing Address: Box 66 Telephone Number:Centeryi 1 l P,Mass _ 02632 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: l o asses nditionally Passes Needs Further Evaluation By the Local Appr ving Authority _ Fail Inspector's Signature- Q Date: 1�W The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 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 have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B)�//One SSYSTEM CONDITIONALLY PASSES: 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. 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 04/25/97) Page 1 of 30 DEP on the World Wide Web: http:1twww.rnapnet.state.ma.us/0ep Printed on Recycied Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 482 Lincoln Road Ext. Hyannis,Mass. Owner: Helen Tufts C/O Sharon Tufts Date of Inspections/15/98 B) SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, senled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health). Describe observations: broken pipes) are replaced obstruction is removed distribution box is levelled 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. t) 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 SO 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: 40 The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. Vo The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. Method used to determine distance IJ& (approximation not valid). 3) OTHER A The design of the present septic system is for a three bedroom house. The house now has four bedrooms.The system is operating properly at this time but is undersized for a four bedroom home. The home is presently 18 years old. (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:482 Lincoln Road Ext. Hyannis,Mass . Owner: Helen Tufts C/O Sharon Tufts Date of Inspection: 6/15/9 8 D) SYSTEM FAILS: You must indicate ei- .er "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 into 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 SAS or cesspool. Static liquid level in the distr'buti n x above outlet invert due to an overloaded or clogged SAS or cesspool. �j ir Liquid depth in casiAed 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). Number 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 I 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 above: _A10- 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 414 the system is within 400 feet of a surface drinking water supply JA 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 04/35/97) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:482 Lincoln Road Ext. Hyannis,Mass. Owner: Helen Tufts c/o Sharon Tufts Date of Inspection: 6/1 5/9 8 Check if the following have been done: You must indicate either "Yes" or"No" as to each of the following: Yes No i --4�/ Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks 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. As built plans have been obtained and examined. Note if they are not available with N/A. Y _ The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. 4 _ The site was inspected for signs of breakout. _ All system components,excluding the Soil Absorption System, have been located on the site. _ 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. —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 System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] (revl*ed 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 482 Lincoln Road Ext. Hyannis,Mass, Owner: Helen Tufts C/O Sharon Tufts Date of Inspection: 6/1 5/98 FLOW CONDITIONS RESIDENTIAL: Design floN. • p.d./bedroom for S.A.S. Number of bedrooms: Number of current residents: Carbage gander (yes or no). i � Laundry connected to system (yes or no)�.* i► Seasonal use (yes or no).A& -�' L%uer meter readings, if available (last two (2) year usage (gpol:T—o I CG, I n a`12G,i- QOi Sump Pump (yes or no):d2o— Last date of occupancy COMMERCIAUINDUSTRIAL: Type of establishment: AN Design flow).gallons/day Grease trap present: (yes or no)&L4 industrial Waste Molding Tank present: (yes or no),4. Non•sanitar� waste discharged to the Tale 5 system: (yes or no)AL14h Water meter readings, if available. I�Iq Las: dale of occupancy: A M OTHER: ;Describer AA Last date 01 occupancy' GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as pan of inspection: (yes or no) ` .; li yes, volume pumped: IWO gallons /�sl �9 r Reason for pumping ,ram yL. G/ TYPE 9f SYSTEM ' Septic tank/distribution box/soil absorption system Single cesspool V Overflow cesspool i Privy Ub Shared system (yes or no) (if yes, anach previous inspection records, if any) All('I/A Technology etc. Copy of up to date contract( Other 4`r/ APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) tr•vi••0 0�/1 S/971 Y•fl• S of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 482 Lincon Road Ext. Hyannis,Mass. Owner: Helen Tufts C/O Sharon Tufts Date of Inspection: 6/1 5/9 8 BUILDING SEWER: (Locate on site plan) 1( Depth below grade: Material of construction: _cast iron Z0 PVC_other (explain) Distance from arivate water supply well or suction line ,f Diameter_1L Comments: (condition of joints, venting, evidence of leakage, etc.) All joints appear tight No evidence of leakage The aUct-Am ; vented through the house vent - SEPTIC TANK: 1069A`�/^`""��� (locate on site plan) e) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene —other(explain) If tank is metal, list age, _ Is age confirmed by Certificate ofCompliance�(Yes/No) Dimensions: f�51f r° Sludge depth: 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 bond of outlet t e or baHle:__j:�5_ How dimensions were determined: 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.) The tank should be pumped every 2-3 years . The inlet & outlet Tees are in place. The septic tank is structural v cr,,,nri nd shows no signs of leakage - GREASE TRAP:A&/,Q, (locate-on site plan) Depth below grade:!¢ Material of constructions/Aconcrete 09metal 1JFiberglasWAPolyethylene i other(explain) lA -- Dimensions: Ally Scum thickness:--A Distance from top of scum to top of outlet tee or baffle: AVA Distance from bottom of scum to bottom of outlet tee or baffle:_,1 Date of last pumping: vot 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.) The grease grease trap not not present (revised 04/25/97) Pag• 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 482 Lincoln Road Ext. Hyannis,Mass. Owner: Helen Tufts C/O Sharon Tufts Date of Inspection: 6/1 5/9 8 TIGHT OR HOLDING TANK:A)ae-(Tank must be pumped prior to, or at time, of inspection) (locate on site plan) Depth below grade: Material of construction:,Qhconcreteg&metal P Fiberglass /,�•PolyethyleneA./Aother(explain) N Dimensions: VA Capacity: gallons Design flow: gallons/day Alarm level: Alarm in working order,(// Yes;4/4 No Date of previous pumping: _ Comments: (condition of inlet tee, condition of alarm and float switches, etc.) Tight or holding tanks arp not present DISTRIBUTION BOX:.Z (locate on site plan) Depth of liquid level above outlet inven: — Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) The distrihution hox has one 1Atpraf No evi pnrp of salids carry AVMs.-Nn gVi-d,gi 3•G,A—O•f 1 PakagP i ntn nr niif of tha rli si-ri hiii-i no box PUMP CHAMBER:d2&00 (locate on site plan) Pumps in working order: (Yes or No). Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appunenances, etc.) Pump chamber is not present_ I (revised 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 482 Lincoln Road Ext. Hyannis,Mass. Owner: Helen Tufts C/O Sharon Tufts Date of Inspection: 6/1 5/9 8 SOIL ABSORPTION SYSTEM (SAS):, (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number: leaching galleries, number:_( D leaching trenches, number,length: leaching fields, number, dime sions: overflow cesspool, number: Alternative system: Name of Technology: / r Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) CESSPOOLS: de (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: AA Depth of solids layer: Depth of scum layer:_ A Dimensions of cesspool: AM Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: , (locate on site plan) Materials of construction:_ /L,'iq Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) (sevi+od 04/25/97) 'Page 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Properly Address: 482 Lincoln Road Ext. Hyannis,Mass . O"ner: Helen Tufts C/O Sharon Tufts Date of inspection: 6/1 5/98 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate al l sv house) wells within 100' (Locate where public water supply comes into o ) t � r l . i Ott 1 t l s (revised 04/15/17) Pay• 9 of 10 Iv SUBSURFACE SEWAGE DISP.. i. SYSTEM INSPECTION FORM I C SYSTEM INFOI: 'ION (continued) Properly Address: 482 Lincoln Road Ext. Hyannis,Mass. Owner: Helen Tufts C/0 Sharon Tufts Date of inspection:6/1 5/98 �, 1 Depth to Groundwater Jb Feet Please indicate all the methods used to determine High Groundwater EI(' ation: Obtained from Design Plans on record Observation of Site (Abutting properly, bservation hole, basemtnl'simp etc.) T Determine it from local conditions Check with local Board of health Check FEMA Maps Check pumping records Check local excavators, installers Use USGS Data Describe n your own words how you established the High GrouncKviier E levation. Must be completed) Used Water Contours Map. Gahrety & Miller MOdel 12/16/94 lrw1..G 0�/23/97) Per. )O�! 30 ya•rnsnr.T-nlTrr.•rr'irn:mr•n>'rwn.-nrtr.nssr�rr.tee-rwmrine*s*nn+mrntrr.a�rra ems+ .T�+-.rr-.T—r-:•.�-.r• I 1 TOWN OF Barnstable BOARD OF HEALTH SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART D •- CERTIFICATION �. ��•Tf't-T••.'::1—T./1T.�.TTTI.TITR1'.f.'1TI T'{lrlrtt'1fa1TTfT.r—S•IT'lIT1�RRRrTC1RR4l.►R�:T.'IC.7 rsm nTesrrnTlrv+TTT.+*r+r•.-.rrr•r.•1:—..� -TYPE OR PRINT CI.EARLY- PROPERTY INSPECTED STREET ADDRESS 482 Lincoln Road Ext. Hyannis,Mass . ASSESSORS MAP, BLOCK AND PARCEL # _ 2 7�z OWNER' s NAME Helen Tufts C/O Sharon Tufts PART D - CERTIFICATION r NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber� & Scnf Ync. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Strevt Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 ) 790 - 1 578 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time of +inspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent With my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : I r ' Systeai PASSED 0_4AIAr�/¢' The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 16 . 303 . Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con Lcted has found that the system fails to Protect the public health and the environment in accordance with Title 5 , 310 CMR 15 . 303, and as specifically noted on PART C - FAILURE CRITERIA of this inspection form . Inspector Signature '0 4 Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the BOARD OF HEALTH. * If the inspection FAILED, the owner or•1"o erator shall u p pgrado • the eysten. Within one year of the date of the inspection, unless allowed or required otherwise as provided in 3.10 CMR 16 , 305 . partd .doc ,I W IIIJJJ (n Z1 ti b rc THE COMMONWEALTH OF MASSACHfUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualifications as required and is hereby authorized to use the title CERTIFIED TITLE S SYSTEM INSPECTOR as provided in 310 CMR 15 .340 and Section 13 of Chapter 21 A of the General Laws. 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