HomeMy WebLinkAbout0048 LINCOLN ROAD - Health 48 Lincoln Road
Hyannis P
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TgWN OF BARNSTABLE
LOCATION ! 0 I^u1//1 RJ• SEWAGE N
VILLAGE-__ 14)141.11 S _ _ASSESSOR'S MAP&LOT 0- 010
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY. 1 r0
LEACHING FACILrrY:(type) l� eI �/J /S (size) 7 NO.OF BEDROOMS 3 nn/r
BUILDER OR OWNER Ib.A/1 Crrl t4l
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching acibty) — Feet
Furnished by
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http://issql2/intranet/Propdata/prebuilt.aspx?mappar-26901 O&seq=1 2/21/2018
TOWN OF BARNSTABLE
LOCATION _ !�`Sr j i ,� r ` SEWAGE #
VILLAGE ASSESSOR'S MAP& LOT
-dl
INSTALLER'S ER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY 1 SG G
LEACHING FACILITY: (type)_ ,,, it-4 To - (size)
NO.OF BEDROOMS_ ?,
BUILDER OR OWNER
I
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
j Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility)
Edge of Wetland and Leaching Facility(If any wetlands exist Feet
within 300 feet of leaching facility)
Furnished by Feet.
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 48 Lincoln rd
Property Address W
Fernando Moura (p ~
Owner Owner's
Name
information is �
required for every Hyannis _ Ma 02601 1918/16 i�i�t(�W ►
page. City/Town State Zip Code Date of Inspection Id 3JRo
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 Michael DiBuono _
use the return Name of Inspector
key.
DiBuono Sewer and Drain
Q Company Name
8 Johns aatth __
Company Address
S Yarmouth Ma 02664
City/Town State Zip Code
508-364-9587 S103522 _
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
10/18/16
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
i
�06eVa
Commonwealth of Massachusetts
9 _ W Title 5 Official Inspection Form
; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
j
g 48 Lincoln rd
Property Address
t Fernando Moura _
Owner Owner's Name
information is required for every Hyannis Ma 02601 1/18/16
.
page. City/Town State Zip Code Date of Inspection
. B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below. -
Comments:
System contains a 1500 GI septic tank as well as a concrete distribution box and 4 infultrators
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 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
48 Lincoln rd
Property Address
Fernando Moura
Owner Owner's Name
information is Hyannis Ma 02601 1/18/16
required for every y _
page. CityfTown State Zip Code Date of Inspection
B. Certification (cost.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b) that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh ,
t5ins•3113 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
48 Lincoln rd
Property Address
Fernando Moura
Owner Owner's Name
information is
required for every Hyannis Ma 02601 1/18/16
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
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/2 day flow
t5ins:3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 48 Lincoln rd _
Property Address
Fernando Moura
Owner Owner's Name
information is Hyannis Ma 02601 1/18/16
required for every �ann —_ _—
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 copylof 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•3/13 - _ Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 5 of 17
i
F
Commonwealth of Massachusetts
P Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Lincoln rd
Property Address
Fernando Moura
Owner Owner's Name
information is required for every Hyannis Ma 02601 1/18/16
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
❑ ® Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Lincoln rd
�M
Property Address
Fernando Moura _
Owner Owner's Name
information is
required for every Hyannis _ _ Ma 02601 1/18/16
page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
System contains a 1500 GI septic tank as well as a concrete distribution box and 4 infultrators
Number of current residents: Vacant
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available (last 2 years usage (gpd)):
Vacant
Detail:
Sump pump? ❑ Yes ❑ 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•3/13 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
48 Lincoln rd
Property Address
Fernando Moura _
Owner Owner's Name
information is
required for every Hyannis Ma 02601 1/18/16
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Not provided . Pumping is recommended
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined? --
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 'rifle 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M e 48 Lincoln rd
Property Address
Fernando Moura
Owner Owner's Name
information is Hyannis Ma 02601 1/18/16
required for every y �— -
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:
11/8/98
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1
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: 1
feet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1500
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 1itle 5 Official Inspection Form Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
9 Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
may% 48 Lincoln_rd
Property Address
Fernando Moura
Owner Owner's Name
information is required for every Hyannis Ma 02601 1/18/16
_
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
24"
Scum thickness 3
Distance.from top of scum to top of outlet tee or baffle 42
Distance from bottom of scum to bottom of outlet tee or baffle 1" Sludge stick
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition structural integrity,
a to rit
9 Y
liquid levels as related to outlet invert evidence of le
akage,eakage, etc.):
No evidence of Ieaking,Tees and or baffles in place at time of inspection.
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•3/13 1itle 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
48 Lincoln rd
Property Address
Fernando Moura
Owner Owner's Name
information is Hyannis Ma 02601 1/18/16
required for every y
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.):
Tees are in place and levels are normal.
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).
ed). Is copy attached? El Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form: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
9 P Yy e is
a/ 48 Lincoln rd
Property Address
Fernando Moura _
Owner Owner's Name
information is Hyannis _Ma 02601 1/18/16
required for every —Y _
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 Level and at normal level
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.):
* 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
;M 48 Lincoln rd _
Property Address
Fernando Moura
Owner Owner's Name
information is Hyannis Ma 02601 1/18/16
required for every y ---. —
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) T
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
11.8x24.8
❑ 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.):
No signs of failure
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth —top of liquid to inlet invert
Depth of solids layer
Depth of scum layer —
Dimensions of cesspool —
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 1itle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 11
Commonwealth of Massachusetts
a _ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
� •� 48 Linc
oln coln rd
Property Address
Fernando Moura
Owner Owner's Name "—
information is
required for every Hyannis Ma _02601 1/18/16
page. City/I own 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.):
No ponding no break out
Privy (locate on site plan):
Materials of construction:
Dimensions ------
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•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
48 Lincoln rd
Property Address T
Fernando Moura
Owner Owner's Name
information is H annis Ma 02601 1/18/16
required for every y _--._—_—_ _ _
page. Citylrown 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
t5ins•3113 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
48 Lincoln rd
Property Address
Fernando Moura
Owner Owner's Name
information is 02601 1/18/16 Hyannis Ma required for every _Y _ _ _
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
❑ Check Slope
❑ Surface water
f ❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: 10+ ft
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: 11/9/98
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:
test hole data on plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins•3113 1itle 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 16 of 17
10/31/2016 Assessing As-Built Cards
TOWN OF BARNSTABLE
LOCATION /mco i SEWAGE#
VILLAGE y4 lot 1 S ASSESSOR'S MAP&LOTa -OIU
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY f 5_0vr U
LEACHING FACILITY:(type) �� ./ rA��l (size)J
NO.OF BEDROOMS 3 r tt om
BUILDER OR OWNER l�A/i l�ri H7,
PERMITDATE: COMPLULNCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching acility) T Feet
Furnished by
1 �
a 33 19
3 3� o1.p
http://www.townofbarnstable.us/Assessing/HMdisplay.asp?mappar=269010&seq=1 112
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
48 Lincoln rd
Property Address
Fernando Moura
Owner Owner's Name
information is
required for every Hyannis Ma 02601 . 1/18/16
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
Inspection Summary
Elp a y Q (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
15ins•3/13
Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
i
r
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECT-10
RECEIVED
JAN 0,6 2004
TOWN OF BARNSTABLE
HEALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
i
Property Address: 48 Lincoln Road
Hyannis, MA 02601 MAP
Owner's Name: Dan Grim
Owner's Address: PARCEL '
Date of Inspection: December 1, 2003 LOT
Name of Inspector: (Please Print) James M. Ford
Company Name: James M. Ford a
Mailing Address: P.O. Box 49
Osterville,MA 02655-0049
Telephone Number: (508) 862-9400
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 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:
i
✓ Passes
Conditionally Passes
Need urther Evaluation by the Local Approving Authority
Fails
Inspector's Signature: Date: December 1, 2003
The system inspector shall sub 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.
Notes and Comments
1
****This report only describes conditions at the time of inspection and under the conditions of use at that
time. This inspection does not address how the system will perform in the future under the same or different
conditions of use.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 48 Lincoln Road
Hyannis, AM
Owner: Dan Griffin
Date of Inspection: December 1, 2003
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.
Answer yes,no or not determined(Y,N,ND) in the 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.
ND explain:
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
obstruction is removed
distribution box is leveled or replaced
ND explain:
j
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
obstruction is removed
ND explain:
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 48 Lincoln Road
Hyannis, MA
Owner: Dan Grim
Date of Inspection: December 1, 2003
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
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 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, provided that:no other
failure criteria are triggered. A copy of the analysis must be attached to this form.
3. Other:
3
Page 4 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
i
Property Address: 48 Lincoln Road
Hyannis, MA
Owner: Dan Grim
Date of Inspection: December 1, 2003
D. System Failure Criteria applicable to all systems:
You must indicate either"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 '/z d ay flow
✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number
of times pumped_.
✓ Any portion of the SAS, cesspool or privy is below high ground water elevation.
_ ✓ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
✓ Any portion of a cesspool or privy is within a Zone 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 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,provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as,
described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large System:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd•
You must indicate either`yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
Yes No
_ the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
_ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area- IWPA)or a mapped
Zone 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.
4
Page 5 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
i
Property Address: 48 Lincoln Road
Hyannis, MA
Owner: Dan Grin
Date of Inspection: December 1, 2003
m
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?
1
✓ 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 Ifor 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?
II
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
Yes No
✓ Existing information. For example, a plan at the Board of Health.
✓ _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance
is unacceptable)[310 CMR 15.302(3)(b)].
I
5
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~Page 6 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
r
SYSTEM INFORMATION
Property Address: 48 Lincoln Road
Hyannis, MA
Owner: Dan Griffin
Date of Inspection: December 1, 2003
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design): 3 Number of bedrooms(actual): 2 I
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
i
Number of current residents: 0
Does residence have a garbage grinder(yes or no): No
Is laundry on a separate sewage system(yes or no): No [if yes separate inspection required]
Laundry system inspected(yes or no): No
Seasonal use(yes or no): No
Water meter readings, if available(last 2 years usage(gpd)): Unavailable
Sump Pump(yes or no): No
Last date of occupancy: Unknown
COMMERCIAL/INDUSTRIAL
Type of establishment: j
Design flow(based on 310 CMR 15.203): end
Basis of design flow(seats/persons/sgft,etc.): {
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no)
Non-sanitary waste discharged to the Title 5 system(yes or no):
Water meter readings, if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records t
Source of information: Unavailable
Was system pumped as part of the inspection (yes or no): No
If yes, volume pumped: eallons--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 contracts(to be
obtained from system owner)
Tight Tank Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information:
Nov. 9198-per as built card
Were sewage odors detected when arriving at the site(yes or no): No
6
Page 7 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 48 Lincoln Road
_ Hyannis, MA
Owner: Dan Griffin
Date of Inspection: December 1, 2003
BUILDING SEWER(locate on site plan)
Depth below grade:
Materials of construction: _cast iron _40 PVC _other(explain):
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage, etc.):
SEPTIC TANK: ✓ (locate on site plan)
Depth below grade: 12"
Material of construction: ✓ concrete _metal _fiberglass _polyethylene
_other(explain)
If tank is metal list age: Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of
certificate)
Dimensions: 1000 gal.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 30"
Scum thickness: I"
Distance from top of scum to top of outlet tee or baffle: 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 10"
How were dimensions determined: Measuring stick
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
Tees were present. The liquid level was even with the outlet invert. There did not appear to be any signs of leakage
GREASE TRAP: None (locate on site plan)
Depth below grade:
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:
Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert, evidence of leakage,etc.):
7
Page 8 of I I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 48 Lincoln Road
Hyannis, MA
Owner: Dan Griffin
Date of Inspection: December 1, 2003
TIGHT or HOLDING TANK: None (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: Qallons
Design Flow: gallons/day
Alarm present(yes or no).-
Alarm level: Alarm in working order(yes or no):
Date of last pumping:
Comments(condition of alarm and float switches, etc.):
DISTRIBUTION BOX: ✓ (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: Even
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.):
The D-box was level and the interior was clean. No solids were present The cover was 16"below Qrade
PUMP CHAMBER: None (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 appurtenances, etc.):
I
8
-Page 9 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY.ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 48 Lincoln Road
Hyannis, MA
Owner: Dan Grim
Date of Inspection: December 1, 2003
SOIL ABSORPTION SYSTEM(SAS): ✓ (locate on site plan,excavation not required)
If SAS not located explain why:
Type
leaching pits,number:
✓ leaching chambers,number: 4 infiltrators w/stone(per as built card)
leaching galleries,number:
leaching trenches,number, length:
leaching fields,number,dimensions:
overflow cesspool,number:
Innovative/alternative system Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level of ponding,damp soil, condition of vegetation,
etc.):
There did not appear to be any signs of failure from the leach field. The bottom to grade was approximately S'
CESSPOOLS: None (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 or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding,condition of vegetation, etc.):
PRIVY: None (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.):
9
• .Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 48 Lincoln Road
Hyannis, AM
Owner: Dan Griffin
Date of Inspection: December 1, 2003
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building.
I �
a 33 19
3 3�
10
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Page 1 I of 1 I
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 48 Lincoln Road
Hyannis, AM
Owner: Dan Grim
Date of Inspection: December 1, 2003
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water 25 +/- feet
Please indicate (check) all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked, date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
✓ Checked with local Board of Health-explain: topographic and water contours maps
Checked with local excavators, installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Using the Barnstable topographic map and water contours map the maps were showing 25'+/-to ground water at this site
This report has been prepared and the system inspected and passed as of the date of inspection. This report is
not a warranty or guarantee that the system will function properly in the future. There have been no warranties
or guarantees, either expressed, written or implied, relating to the system, the inspection and/or this report.
11
e �4.
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JL�F�c
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
d
v y
TITLE 5 ` Y
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS , .
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM �Ea
t�3�tf
PART A l
CERTIFICATION
Property Address: 48 LINCOLN.RD HYANNIS,MA 02601 ���
Owner's Name: ESTATE OF LILLIAN AMESDEN
Owner's Address: C/O GRANT AND LEE765 FALMOUTH RD.HYANNIS s
Date of Inspection: 11/5/01 RECEIVED }i
Name of Inspector: (please print) JOHN GRACI 1
Company Name: SEPTIC INSPECTIONS
Mailing Address: P.O.BOX 2119 TEATICKET,MA.02536 Yh ;
TOWN OF BARNSTABLE
Telephone Number: 508-564-6813 FAX 508-564-7270 HEALTH DEPT
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 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: ,
X Passes <,
_ Conditionally Passe }4 ;
Needs Further v ation by the Local Approving Authority u.
Fails
Inspector's Signature: Date: 11/5/01
1, ��`-•.��}�'
The system inspector shall submit a opy of this inspection report to the Approving Authority(Board of Health or DEP)within ,
30 days of completing this inspect . 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 bex
sent to the system owner and copies sent to the buyer, if applicable,and the approving authority.
..x
Y '
Notes and Comments `
THE SYSTEM PASSES TITLE V INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS FOR r
MAINTENANCE.RECOMMEND RAISING COVER TO LEACH FIELD.
****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.
y ,
1
Titla 5 Incnrrtinn Fnrm 6/15/?f111F1
t
Page 3 of 11
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
t ` r4y:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ,
PART A
CERTIFICATION(continued) . .
Property Address: 48 LINCOLN RD HYANNIS,MA 02601
Owner: ESTATE OF LILLIAN'AMESDEN
Date of Inspection: 11/5/01
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 ;`f
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:
�w
_ Cesspool or privy is within 50 feet of a surface water tr .
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or.a salt marsh
P P �'Y g g
- - % I
7�f
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: „
,i-wir w
_ The system has a septic4ank 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. k1++=.
IT,
_ The system has a septic tank1fid 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. "�t ,•
supply well".Method used to determine distance n/a n x
"This system passes if the well water analysis,performed at a DEP certified laboratory,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,p triggered. " X
PY � X.
provided that no other failure criteria are ered.
r ►gg A co ,r
of the analysis must be attached to this form. k
3. Other: {' ?
n/a fi
aF
tT'
Page 2 of 1 I
h
s OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS ' .
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM a�
PART A ¢f4��=
'CERTIFICATION (continued)
Property Address: 48 LINCOLN RD HYANNIS,MA 02601V,
Owner: ESTATE OF LILLIAN AMESDEN
Date of Inspection: 11/5/01
Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D
n
A. System Passes:
X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 1:
CMR 15.304 exist.Any failure.criteria not evaluated are indicated below. ,
Comments:
THE SYSTEM PASSES TITLEFV INSPECTION.RECOMMEND PUMPING EVERY TWO YEARS FOR
MAINTENANCE.RECOMMEND RAISING COVER TO LEACH FIELD.
#; +
B. System Conditionally Passes:,
_ One or mores stem components as+described in the Conditional Pass section need to be replaced or repaired.The s stem
Y P P P Y
upon completion of the replacement or repair,as approved by the Board of Health,will pass. ;r
Answer yes,no or not determined(Y,N,ND),in the for the following statements. If"not determined"please explain. x
n/a 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 T
that the tank is less than 20 years old is available.
e .
1 ND explain: n/a
n/a Observation of sewage backup'or break out or high static water level in the distribution box due to broken or obstructed 5.> �#
pipe(s)or due to a broken,settled or'.uneven distribution box.System will pass inspection if(with approval of Board of x ks
` Health): tk;
'broken pipe(s)are replaced
obstruction is removed kx
�2 distribution box is leveled or replaced 3 .
ND explain: n/a
n/a 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 pipes)are replaced
_obstruction-is 6moved "
ND explain: n/a t
9.A
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t
Page 4 of I 1 y
# �y
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS hs; "
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 48 LINCOLN RD HYANNIS MA 02601
Owner: ESTATE OF LILLIAN AMESDEN
Date of Inspection: 11/5/01 4 *
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or"no"to each of the following for all-inspections:
Yes No
aa;s
X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
_ X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool N
X Liquid depth in cesspool is less than 6"below invert or available volume is less than '/z daY flow x
q P P
q pumping Y gg pip ( ) `
_ X Requiredmore than 4 times in the last year N(1T due to clogged or obstructed i e s .Number of times .0
pumped nLa.
_ X Any portion of the SAS,cesspool or privy is below high ground water elevation. a , �
X Any portion of cesspool or privy,is within 100 feet of a surface water supply or tributary to a surface water supply. zkf
_ X Any portion of a cesspool or privy is within a Zone 1 of a public well. ���
X An portion of a cesspool or privy is within 50 feet of a private water supply well. F =�
Y p P P �'Y P PP Y �
_ X Any portion of a cesspool or privy.is less than 100 feet but greater than 50 feet from a private water supply well with
3 no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP kin,
i certified laboratory,for coliform bacteria and volatile.organic compounds indicates that the well is free;
from pollution from lthat facility 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.]
(Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system fails`;The system owner should contact the Board of Health to determine what will be ..y v
necessary to correct the failure.
i 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. �r�a
You must indicate either"yes"or"no"to each of the following: :
(The following criteria apply to large systems in addition to the criteria above) '
yes no
X the system is within 400 feet of a surface drinking water supply
4
_ X the system is within 200 feet of a tributary to a surface drinking water supply ,
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped :r :,
Zone Il of a public water"supply well : x
.! ar
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 largeesy§tem"l as 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
t should contact the appropriate regional office of the Department. i;
' Y
A
4 5
IPage5 of 11 , s
t
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS `'
1 k.;
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM `
PART B `
CHECKLIST 7
Property Address: 48 LINCOLN RD HYANNIS,MA 02601 `Fr
Owner: ESTATE OF LILLIAN AMESDEN
Date of Inspection: 11/5/01 „ .
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
iX
. tiA
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health ,
. P,
X Were any of the system components pumped out in the previous two weeks?
X _ Has the system received normal flows in the previous two week period? �*
_ X Have large volumes of water been introduced to the system recently or as part of this inspection? q
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) yea ,y ,
X _ Was the facility or dwell►ng.inspected for signs of sewage back up? w
X _ Was the site inspected for signs of break out? t 3
X _ Were all system components,excluding the SAS, located on site? Ok
' X 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? ru''t '
t V
L tl,:t
X _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance {* _# `
of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has been determined based on:
' Yes no
_ X Existing information.For'ezample,a plan at the Board of Health.
X _ Determined in the field' if an of the failure criteria related to Part C is at issue approximation of distance is
i ( y pP
unacceptable)[310 CMR 15.302(3)(b)]
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Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
a
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 48 LINCOLN RD HYANNIS,MA 02601
Owner: ESTATE OF LILLIAN AMESDEN
Date of Inspection: 11/5/01
FLOW CONDITIONS °
RESIDENTIAL
Number of bedrooms(design):3.} Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):330 '
Number of current residents:0
Does residence have a garbage grinder(yes or no): NO 5 ,
G n
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required] T
Laundry system inspected(yes or no):NO
Seasonal use:(yes or no):NO x
Water meter readings,if available(last 2 years usage(gpd)): n/a '"
Sump pump(yes or no): NO
l �x
Last date of occupancy: n/a
COMMERCIAL/INDUSTRIAL
.:
Type of establishment: n/a
Design flow(based on 310 CMR 15.203): n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no):NO
Industrial waste holding tank present(yes or no): NO �,4k
Non-sanitary waste discharged to the Title 5 system(yes or no): NO
s Water meter readings,if available: n/a ,
Last date of occupancy/use: n/ay np''
OTHER(describe): n/a a.
GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of the inspection(yes or no): NO
If yes,volume pumped: n/agallons--How was quantity pumped determined?n/a
Reason for pumping: n/a
' TYPE OF SYSTEM v
r
i X Septic tank,distribution box,soil absorption system ,` J ,'
' 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 f '
system owner) # 4 Y
_Tight.tank Attach a copy of the DEP approval ,
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information: .
1998
Were sewage odors detected when arriving at the site(yes or no):NO ,;
ap 1[k• .
x
Page 7 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) '
Property Address: 48 LINCOLN RD HYANNIS,MA 02601
Owner: ESTATE OF LILLIAN AMESDEN
Date of Inspection: 11/5101 .-
BUILDING SEWER(locate on site plan) aspx
i Depth below grade:30" f p
Materials of construction:_cast iron X40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,evidence of leakage,etc.): r aas
TOWN WATER
SEPTIC TANK: X(locate on site plan) .4 {
Depth below grade:24" r'
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a <r
If tank is metal list age: n/a Is age confirmed b a Certificate of Compliance es or no : NO attach a co of certificate g g Y P (Y ) ( PY )
Dimensions: 1250G L 10' H 5' 7'! W 51:'
Sludge depth:0" s
`
Distance from top of sludge to bottom of outlet tee or baffle:34" 1 ;
M
Scum thickness: 1" F
Distance from top of scum to top of outlet tee or baffle: 6"
} Distance from bottom of scum to bottom of outlet tee or baffle: n/a
How were dimensions determined: MEASURED
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related `
e
to outlet invert,evidence of leakage,etc.): "
THE SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING ,�5 � �-.
PROPERLY. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE SYSTEM'S USEFULL LIFE '#`
SYSTEM. --
r;
''atYy '��'-.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a F
Dimensions: n/a ;
Scum thickness: n/a
*
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
=�
Date of last pumping: n/a ',
Comments(on pumping recommendafions,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related
to outlet invert,evidence of leakage,'etc.):
Ya Y r
Ji
}
3 r A
a,
Page 8 of 11
S
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued) 't
Property Address: 48 LINCOLN RD HYANNIS,MA 02601 ` k
Owner: ESTATE OF LILLIAN AMESDEN
Date of Inspection: 1115101 x�
TIGHT or HOLDING TANK:' (tank must be pumped at time of inspection)(locate on site plan) r�YYi
Depth below grade: n/a
}`
Material of construction:_concrete_metal_fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Capacity: n/a gallons ..
Design Flow: n/a gallons/day
Alarm present(yes or no): N/A t
Alarm level: N/A Alarm in working order(yes or no):NO
Date of last pumping: n/a r;
Comments(condition of alarm and float switches,etc.): t "
P 4
n/a
DISTRIBUTION BOX:X(if present must be.opened)(locate on site plan)
Depth of liquid level above outlet invert: LEVEL WITH BOTTOM OF PIPE
Comments(note if box is level and distribution to outlets equal,an evidence of solids carryover,
q � Y rryover,any evidence of leakage into
or out of box,etc.):
BOX IS STRUCTURALLY SOUND. r �x
PUMP CHAMBER:_(locate on site plan) eti,
2
Pumps in working order(yes orkno):NO i..
Alarms in working order(yes or no):NO° jar_
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
€ n/a
a
M1
ut
y
yd
Page 9 of 11
{ .� .T
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
�w
Property Address: 48 LINCOLN RD HYANNIS,MA 02601
Owner: ESTATE OF LILLIAN AMESDEN
Date of Inspection: 11/5/01 .
Z
SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required)
If SAS not located explain why:
n/a .
Type
n/a leaching pits, number: n/a
INFULTRATORS leaching chambers, number: 4
n/a leaching galleries, number: n/a xk.
n/a leaching trenches, number, length: n/a 'Y =�
n/a leachingfields, number: n/a
n/a overflow cesspool, number: n/a
n/a �,_� ffi innovative/alternative system
Ty
pe%name of technology: n/a
�..' �.
Comments(note condition of soil,signstof.hydraulic failure, level of ponding,damp soil,condition of vegetation,etc.): `
THE LEACH FIELD APPEARS TO BE�FUNCTIONING PROPERLY.RECOMMEND RAISING INSPECTION
COVER. BOTTOM AT 6' 3.
CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) ;;. < ,
Number and configuration: n/a + ,
Depth—top of liquid to inlet invert: n/a .,%Y
Depth of solids layer: n/a
Depth of scum layer: n/a ,
Dimensions of cesspool: n/a
Materials of construction: n/a
w d �
Indication of groundwater inflow(yes or no):NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a •.
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a 9`
Depth of solids: n/a
skf
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): #NfJ
n/a t� ;.
9i M
Page 10 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS Y "w ?
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORMi"
ti4 k 4.
PART C ,'
SYSTEM INFORMATION(continued)
Property Address: 48 LINCOLN RD HYANNIS,MA 02601 "
Owner: ESTATE OF LILLIAN AMESDEN �
Date of Inspection: 11/5/01
SKETCH OF SEWAGE DISPOSAL SYSTEM a"
Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. ,,
Locate all wells within 100 feet.Locate where public water supply enters the building.
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Page 11 of 11
A
�J
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM "
PART C
SYSTEM INFORMATION(continued) '
Property Address: 48 LINCOLN RD HYANNIS,MA 02601
Owner: ESTATE OF LILLIAN AMESDEN `
Date of Inspection: 11/5/01
SITE EXAM
s�
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 10+feet <<'
Please indicate(check)all methods used to determine the high ground water elevation: r.
NO Obtained from system design plans on record-If checked,date of design plan reviewed: n/a
4
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local excavators, installers-(attach documentation) `
NO Accessed USGS database-explain:,n/a >,
15
You must describe how you established the high ground water elevation:
GROUNDWATER DETERMINED BY AUGER-NO WATER AT 10' BOTTOM OF FIELD AT 6'
1
TOWN OF BARNSTABLE
.,t. p
LOCATION 1�l CIJ16 R�- SEWAGE #
�L LAGE 1 Y4l-t IS ASSESSOR'S MAP & LOTO�
INSTALLER'S NAME&PHONE NO.
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) l4 ,() r07�il (size) 7
NO. OF BEDROOMS 3 .
BUILDER OR OWNER Ib BUILDERGrp ^
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge,of Wetland.and Leaching Facility(If any wetlands exist
within 300 feet of leachingfacility) �—�- Feet
Furnished by 9,— CCD 6-n
��
� �
� 3 t
� O O
a33i�b . , .
3 3�
TOWN OF BARNSTABLE
LOCATION I / SEWAGE # 71
—
VIILLAGE I I/.1�r,✓r'� ASSESSOR'S MAP& LOT 6113
INSTALLER'S NAME&PHONE NO. /Vl r /0 r -4 0--e 1 a-11 -f_
SEPTIC TANK CAPACITY SU G �"sl ti k
LEACHING FACILITY: (type) l TR.II Tvr3 (size)
NO.OF BEDROOMS
BUILDER OR OWNER Ikft
PERMTTDATE: I5 "^�1 Y COMPLIANCE DATE: lI,•� ' —�/ '
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 exist
within 300 feet of leaching facility) Feet
Furnished by
cz
i.
X
No. 91 7 Feec
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01pplication for 33i_4p0$al *p$tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) gComplete System El Individual Components
Location Address or Lot No.(-A D L)N co k io ITy Owner's Name,Address and Tel.No.
Assessor's Map/Parcel �.�Cl " 6�� �� ' r'�coj
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Type of Building:
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow '33C7 gallons per day. Calculated daily flow gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank 1 S" 5%7% Type of S.A.S. U,%Q C C1L
Description of Soil C442�
Nature of Repairs or Alterations(Answer when applicable) =N 51 v.,-)M I SOD S� 1 , D g0 xc
P—WOt t ^!1 1 � a
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued d of �l l
Sign Date
Application Approved by Date
Application Disapproved for the llowi g reasons
Permit No. — � l f3 Date Issued
�.`i,\..y �.+'.t _� &`. � J 'Lr'!R^t ] ..y.itiN4..,''^it i"�;ru'°f-rarr... :i+5+8.,J i,..-.,. s..•. , -- ....... •R:
{ -
�` ./
Fee
THE.COMMONWEALTH OF MASSACHUSETTS Entered in computer:
r` Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZippYication for Miopaar *p.5tem Construction Permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) gComplete System ❑Individual Components
Location Address or Lot No. (A,9U N Gv 41 Owner's Name,Address and Tel.No.
Assessor's Map/Parcel 9 OR — 00
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
c�C-, Q 19kT C fl, h�
Type of Building:
Dwelling No.of Bedrooms "3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow 73n gallons per day. Calculated daily flow 7" gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank t ""'y rTKi k,-r �_T_i'?Typeo f'S.A.S. l` 4 \KCk V26t r k �L- �1---
Description of SoilQ
Nature of Repairs or Alterations(Answer when applicable) —=Vv ST VA1 I Sop SIT, 17--60 x
�Lfn
Date last inspected:
Agreement: ;
The undersigned agrees to ensure,the construction and maintenance of the afore described on-site sewage disposal system
.3
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been issued b l and of q
Date Signe /���_!
Application Approved by I e 4 Date /1 -
Application Disapproved for the PloWi reasons
Permit No. - / ff Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded({/�
Abandoned( )by - S=
at N r~I- has been constructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. 7 l 9 dated
Installer c: _ Designer
The issuance of this permit shall not be constrikd,,as,a guarantee that the system will function as designed.
Date 'Ic � - 5& 'Inspector
�r: \
-- -1 - .�---- --------------
No. i - / / ----- Fee
\THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION-� BARNSTABLE, MASSACHUSETTS
'i!6pogal*p�tem`,Con! truttion Permit
Permission is hereby granted to Construct( )RepatrP( Up radep4bandon( )
System located at L1 '� U ,✓ ,t
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Construction must be completed within three years of the date of this permit.
Date: 1 -``/r �/ Approved by ,
10/9197
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems OnIk.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
hereby certify that the application for disposal works ,
construction permit signed by me dated /� 78 , concerning the 1
property located at C'y, `'� ►ti�`�S meets all of the
i
following criteria:
There are no wetlands located within 100 feet of the proposed leaching facility
There are no private wells within 150 feet of the proposed septic system
There is no increase in now and/or change in use proposed
There are no variances requested or needed.
If the proposed leaching facility will be located within 250 feet of any wetlands, the bottom of the
e ` proposed leaching facility will aM be located less than fourteen(14) feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map)
B)Observed Groundwater Table Elevation(according to Health Division well map)
3 C/1
SIGNED
DATE: I '7 F
LICENSED SEPTIC SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
(Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
q:hedth lbldee val
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