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Home My WebLink About0148 MEGAN ROAD - Health 148 MEGAN ROAD Hyannis A= 291 -258 f e � i TOWN OF BAJRNSTABLE LOCATIONS SEWAGE# 19 /35'j VILLAGE G ASSESSOR'S MAP&PARCEL INSTALLER'S NAME&PHONE NO. mx SEPTIC TANK CAPACITY �� i�() (.,Cl BID � � .®26 LEACHING'FACILITY:(type) C2 bL) Gr-� (size) d L-1 !'` ' NO.OF BEDROOMS >.OWNER .CL&(Xi ns,I P d o PERMIT DATE: 11:1(I C\ COMPLIANCE DATE: separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility °Y Feet Private Water Supply Well and Leaching Facility(If any wells exist on ' site or within 200 feet of leaching facility) ka Feet 'Wd of Wetland and Leaching Facility(If any wetlands exist within t ':300 feet of leaching facility) ` Feet , FURNISHED BY a ,F r GY CP Cl� ' �®� Lu e o • TOWN OF BARNSTABLE :LOCATION /�� SEWAGE # 'VILLAGE ASSESSOR'S MAP LOT :INSTALLER'S NAME PHONE NO. :SEPTIC TANK CAPACITY ®� ( �.� Lo L,4 T'e- :;LEACHING FACILITY:(type) �� (sue) L X NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER ZUILDER OR OWNER yle-l", DATE PERMIT ISSUED: -fDATE COUPLIANCE ISSUED: �� "VARIANCE GRANTED: Yes No .. J r �� ' � �_ � � S �` s '' �" I ~ 1 d � ,� W t. Av/ No � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Ye 9ppfitation for Misposal 0psti m Construction Vermit Application for a Permit to Construct( ) Repair(VII) Upgrade( ) Abandon( ) ❑Complete System [Xndividual Components Location Address or Lot No. `l l M C-5 A r N Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ��\ ZSV W o.Ncy mdVrG\,d i An Installer's Name Address and Tel.No. Design r' ame ss d Tel o. 5 e%AA C nY '�\3 G 1� yc�r��v �� co �., [ ds o y�3 2J 3I� c toy S. C o c_ 52f Type o uilding: Dwelling No.of Bedrooms 2 Lot Size sq.ft. Garbage Grinder Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures ^ /` Design Flow(min.required) J_ gpd Design flow provided u . U gpd Plan Date Number of sheets Revision Date Title ` Size of Septic Tank !�'C r�'![ b Cj Type of S.A.S. nci (s ca— W l u G%,,G„ti 6 t_rS Description of Soil Nature of Repairs or Alterations(Answer when applicable) Q� L4)['Teti b t. �1 d k x C ox 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 Certificate of Compliance has been issued by this Board ealth. C� c Cigned Dateoow Application Approved by Date ..Application Disapproved by Date for the following reasons _ Permit No. ��` Date Issued �tr No Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN-GE,13ARNSTABLE, MASSACHUSETTS Ye ftpliLation for Bisposal 6pstem Const urtlon Vrrrd t Application for a Permit to Construct( ) Repair V Upgrade( ) Abandon( ) ❑Complete System Eidividual Components Location Address or Lot No. ,y (v\c C^n J Owner's Name,Address,and Tel.No. Assessor's Map/Parcel N c_e\c Y C"1 tlUr A U\ C Installer's Name,Address,and Tfel.No. Designer's Name,Address,and Tel.No. jcot\ �_,r \v. c) % SS Gco Rydv R J rAr Type of uilding: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder(�Jp Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) 1 gpd Design flow provided g�� gpd r Plan Date h Number of sheets D Revision Date Title Size of Septic Tank e X k5N r, Type of S.A.S. �C,6 ` �.{ ( ,��t (,t_r S Description of Soil ..J Nature of Repairs or Alterations(Answer when applicable) sGQ� ' 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 Certificate of Compliance has been issued by this Board of Health. geed Date 9 if Application Approved by Date n Application Disapproved by / Date for the following reasons Permit No. I Date Issued --------------------------------------------------------------------------------------------------------------------------------------- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE,MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) RepaireV) Upgraded( ) Abandoned( )by fS r- at ' has been constructed in accordance with the provisions of Ti e 5 and the for Dispos 1 System Construction Permit N" dated Installer � � ^�� Designer #bedrooms�\ Approved design flow '> > gpd The issuance of this permit shall of be con trued as a guarantee that the system w'kYfunctio s-desi ed. Date1 �j Inspector ^� --------------------------------- -------------------------------- No� 3 5 r Fee e THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION -BARNSTABLE,MASSACHUSETTS MispoBal Opstem Construction permit Permission is hereby granted to Construct( ) Repair(L,-< Upgrade( ) Abandon( ) System located at \ l t (��, r� and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction mus be completed within three years of the date of this p it.7U,S. Date (f !r 1 Q Approved b R t '- Town of Barnstable C2e,ulatory Services Richard V , call, hnEcrini Director HARNSTAB1 C ,t �+^ PublicHealtl Drvi'sit>'n rho mas McKeon, Director 200 Main ,street,Hys►n' his,;N1A:02f0;1 Catiice'.: SU>l >312 Gi4t fax? SUli 7c?0 tt3h -Installer&..nesigner Date: cf I z Iy i CerfiiGation Form 4Seva Perrnt# rdssesscrtiMa \'arccic n � s f Desil nt r. v to AddreSc S,S 2; dQr � �OA Address': y t On. I i '` �r1C �'(i•/�"CIS"tssiied a hermit to tnstalk.�i; (date} Cinstalaer); SCp)lt.C;SyStCITt at �; '! �� d ba'sc;.d on a;designzira�vn,by (address}, c�t'i , . t1 tn0� dated' �t 1 ? t (designer) . 1 ccrt'iiy:th rt the klitic s:ystein referenced itb:ove.was installed sutistariti:illy according'tti iihc dgstgn,which`inay illetude niinor 4ipl)r�)Y'(,ci,changes such as latertil'rclncatietn of t!>e dtstrtbt�`ittof `box.and/or` optic.t�tnk.. :Strl aut.(if'rc quiredYvds fir sl�ccted anti rho soi•is;. were>"fotund satin factory, t . 1 cert'ify that tI- :septic'systcii� r�fercnctil rtbcauc.was rnstallcd with major cliangcs gtLaterlihan ;IV lat' I relocrttiu l bf the-SAS i�r any �1c t2ical,;s c locat on"c�.,any component: 'f the;septic.., yacria) but ill accordance with State & Local !regulations. I?lan.revt5ton or; butified.as-btitlt hy::designer to,follow. Strip out.01"requiritd wits inspected at d'thc.soils: were ioutid='satisfactory., I certify that the system referenced abovice was,0i structed-in e`wtthahe.tet s' of the11A Ktplatcival'lcttcrs(il'alplicctb"!e) otit � . . �la�Ut?Ht{tVOM. Inatalle s'. ignature, , Nb-1093, . (IJcsigncr's Signature) (Affix Designer s Ia;Flcr�) KEEASE.R"E,rURN `I'O I3ARNS`l'ABI.I!; PUBLIC HEAt.,'I'I•I DIVISION. ,CER'I'I.FfCAjT OF -COMPLIANCE WILL :NOT BE' ISSUED, UN'I'Ii,. BOTH THIS FORM AND."AS-: i BU LT CARD ARE"RECEIVED BY''TH)h BARNSTA13I:E PUBT.IICr.HEALTH.DIVISi.ON., fHANK-YOV V 1 �ptcllcsibntrGcnitc7tt<m t'cintt CteJ ft:=1d M� " �0 ',a _ PNSSPBLE GIS D_ DAI GMT D: ELEVATION 53.24 W0A �AVEMENt. $,- TOP of FOUNDPj\�� EDOE _- M - 4 4 51 p p 2 ® aw9 n VT§L�§T§ S IL— O T 3,.4C +� ,. WATER LINE 30' ", , AREA = 12359 sf+- GAS LINE 51_ G LAND COURT PLAN 27099-B oas DATE 0 ASSR MAP 291 PCL 258 OVERHEAD WIR off y DRAIN i u it L 0. i - 2.. G _- GARB I p � OT MINIMAL OWED % GRADING THIS IS A PROPOSED COLOR = =-- _51 9% E\IloU o USE COLOR PLANPLA ONLY D, / C T Y P 1 sOA�oNr 20 in ` FOR INSTALLATION �' / TREE ` FULL DETAIL IS BEST VIEWED IN 14 PROPOSED SOIL FULL COLOR ABSORPTION 2 SYSTEM $�ED -SEE DETAIL ON BACK G SEPTIC COMPONENTS 5 0 - — R ` ,1 EXISTING ��O V SEPTIC TANK OEXISTING ° LEACH PITI ` \ 4000 CESSPOOL DISTRIBUTION BOX0 1agb Et 50 PLAN TEST PI _ SCALE: I in = 210 ft 0 20 40 EXISTING LEACH PIT TO BE o Io 20 PUMPED AND FILLED OR REMOVED PRINT ON 8-1/2 x 14 in PAPER FOR PROPER SCALE THIS PLAN IS INTENDED SOLELY FOR INSTALLATION OF.THE SEPTIC SYSTEM DEPICTED ON IT. FOR ANY OTHER CHANGES TO THE PROPERTY INCLUDING - PLACEMENT OF ADDITIONS. SHEDS, FENCES OR SWIMMING POOLS. OWNER QUTH RD _ SHOULD CONSULT WITH A MASSACHUSETTS REGISTERED LAND SURVEYOR. PALM OF _ � ROUTE 28 ccP��)A 0 �PS� OF MASS9. NOT off' DAviD y� �s`/ ` �ti Oo aTF SEWAGE DISPOSAL CIA RD To D. �o D DviD Ill, �� y SYSTEM PLAN pL1 �� SCALE u COUGHANOWR N � c UGHANOWR N` ? t Rt F L?idt iIJ(; v No. 1093 � m 9 ' No. 461 o Nf� NANCY N av �Fcl ��.�P Rov�o .�. MOURADLAN ELDRIDOE Sq p, o iotlis R E SP° 148 ME(3AN ROAD 155 Geo Ryder Rd S HYANNIS, MA L;._"_, HYANNIS. MA Chatham, MA 02633 Davidcou@HotmaiLCom =' _ SEPTEMBER 17. 2019 L 0 US MAP 508 364-0894 = .1/2 _)oL ETE-4407 naco'E AIL TNT Wain REGION CALCULATIONS SOIL EVALUATOR: DAVID D. COUGHANOWR.. ASE *461 DESIGN FLOW: 2 BEDROOMS X 110 GPD = 220 GPD WITNESSED BY: DONALD DESMARAIS. HEALTH DEPT. J NO GROUNDWATER ENCOUNTERED SEPTIC TANK., 220 GPD X 2 DAYS = 440 GALLONS TEST PIT 1 PERC AT 64 In - 2 MIN/INCH IN C SOILS USE EXISTING 1000 GALLON SEPTIC TANK IF IN ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER t SOUND.STRUCTURAL CONDITION. IF NOT. INSTALL 50.50 INCHES HORIZON TEXTURE (MUNSELL) MOTTLES NEW 1500 GALLON) SEPTIC TANK. 0-12 FILL DISTRIBUTION BOX, INSTALL UNIT DEPICTED BELOW. I 12-20 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE SOIL ABSORBTION SYSTEM: 20-45 Bw LOAMY SAND 10 YR 5/6 NONE FRIABLE 46.75 THE LONG TERM ACCEPTANCE RATE FOR A CLASS ONE 45-1351 C LOAMY SAND 10 YR 5/4 NONE LOOSE SOIL WITH A PERCOLATION RATE BELOW 5 MINUTES 39.25 PER INCH = 0.74 GALLONS PER DAY PER SQUARE FOOT. TEST PIT 2 NO GROUNDWATER ENCOUNTERED 2 MIN/INCH IN C SOILS THE 24, ft x 12.83 ft x 2 ft LEACHING GALLERY (WITH ELEVATION DEPTH SOIL USDA SOIL SOIL COLOR SOIL OTHER : CUT CORNER) DEPICTED BELOW CAN LEACH: INCHES HORIZON TEXTURE (MUNSELL) MOTTLES 50.40 BOTTOM AREA (24xl2.83)-1/2(3X3) = 303.4 Sq. ft. 0-10 FILL SIDEWALL AREA = (24+21+12.83+9.83+4.24)x2=143.8 s ft. 10-18 Ap SANDY LOAM 10 YR 3/2 NONE FRIABLE 18-42 Bw LOAMY SAND 10 YR 5/6 NONE FRIABLE TOTAL AREA = 447.2 sq. ft. 4 6.9 0 42-132 C LOAMY SAND 10 YR 5/4 NONE LOOSE FLOW CAPACITY = 0.74 x 447.2 = 330.9 g a I/d o y 39.40 _ INSTALL THE PROPOSED LEACHING GALLERY AS CONFIGURED BELOW. FLOW CAPACITY = 330.9 gal/doy WHICH EXCEEDS 1000 GALLON SEPTQC TANK THE 220 gal/day REQUIRED FOR A TWO BEDROOM DESIGN. EXISTING UNIT DIMENSIONS & DETAIL TANK TO BE PUMPED DRY AT TIME OF INSTALLATION S O§L Q.o S Oo R P IT§0 H AND EXAMINED FOR STRUCTURAL INTEGRITY. INSTALL �� CONSTRUCTION DETAIL NEW PVC OUTLET TEE EQUIPPED WITH A OAS BAFFLE. REPLACE WITH A NEW USE SHOREY PRECAST 500 'GALLON LEACHING DRYWELL I in 1500 GALLON TANK 3 ft DRYWELL l TAPER � . IF .CRACKED. ROTTED 21.0 ft NITS OR OTHERWISE COMPROMISED. _ P _Y C41 N p� N O00 co AT NOT TO SCALE .1\0 \ �ON� 3.5 ft 8.5 ft 8.5 ft 3.5 ft 8 ft-6 500. GALLON DRYWELL INLET OUTLET DIMENSIONS & DETAIL INSTALL ONE INSPECTION COVER COVER - RISER TO WITHIN THREE USE INCHES OF FINAL GRADE 3 IN DROP H-10 & INDICATE LOCATION �l FLOW LINE UNIT ON AS=BUILT FROM a TO BUILDING 10 In in D-BOX 33 + 1 . - +� 48 in :r. � ,. �p� in �$od LIQUID GAS LEVEL, 102 0 b"in- STONE BASE IF NEW` SEPARATION BETWEEN INLET I& OUTLET CROSS SECTION VIEW TEES NO LESS THAN LIQUID DEPTH INSTALL AN APPROVED GEOTEXTILE CROSS SECTION VIEW FABRIC OVER STONE 1� 1 /V V 1 YY a•;,1,�#.{�' x�#zkt� �ix� t t, r o p o M USE SHOREY $ rtztwrt .'a■ ■ �• it z .?: D§5 TR§2UT§0# Ecc DB-3 H2O 28 z 3/4 In TO n;■ LEFFL� RAIVE■,1 1/2 InDIMENSIONS PIPES EXITING D-BOX TO RUN LEVEL in =x _�. ^5' ■ ■ r z + AND DETAIL FOR 2 FEET BEFORE PITCHING DOWN 3 � txt r 46 in 58 in 46. in 12 In J 150 in = MIN - -� -INSTALLER TO OBTAIN DISPOSAL WORKS PERMIT BEFORE Lo FROM = -S STARTING WORK. N TANK u) to TO ALL COMPONENTS INSTALLED SHALL MEET THE MINIMUM K SASOO REQUIREMENTS OF MASSACHUSETTS TITLE 5 SEPTIC O a CODE (310 CMR 15). IJ_y -ECO-TECH RAPID RESPONSE RECOMMENDS THE INSTALLATION \ 6 In STONE BASE �` OF LOW FLOW FIXTURES & APPLIANCES. AND PERIODIC 21 ;n 2 CROSS SECTION VIEW PUMPING OF THE SEPTIC TANK. -SYSTEM NOT DESIGNED TO WITHSTAND VEHICULAR LOADING. S DO NOT PARK OR DRIVE VEHICLES OVER SEPTIC SYSTEM. F L 0 W p Fff)) 0 F L TOP OF FOUNDATION RAISE COVERS TO WITHIN Qj��A'PNDTO BE 4 to SCH. 40 PVC EL = 53.24 + b In OF FINAL GRADE TO PITCH AT 1/8 In/ft MIN `. 50.50 I ®-BOAC 3. USE H20 - .TEE M A X - EXISTING 47.50 EXISTING 1000 GALLON - PRECAST = � 48.15 r_fr z % ,.Y DRYWELL SEPTIC TANK 6 in F_XI�TING REFER TO DETAIL BOX STONE SOL ABSORPTION 47 00 BASE 46.75 6 in BASE IF NEW ��EM -REFER TO O EXISTING 9 ft I b ft DETAIL BOX n NO GROUNDWATER V BELOW 44.75 MOTTLING OBSERVED-4- 39.25 SEWAGE DISPOSAL SYSTEM PLAN 1148 MEGAN ROAD HYANNIS. MA 11SEPTEMBER 17. 2019 ETE-4407 �oFiTq�ti Town of Barnstable P Inspectional Services Department BA ABLE, HAS& Public Health Division i639• �� prf°'"Aye 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKcan,CHO CERTIFIED MAIL#7015 1730 0001 4988 1319 August 27, 2019 MOURADIAN,NANCY 117 HILL STREET APT 205 STONEHAM, MA 02180 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 The septic system located at 148 Megan Road,Hyannis, MA was inspected on 07/31/2019 by Sean M. Jones, certified Title V Septic Inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Fails" under the guidelines of 1995 TITLE V (310 CMR 15.00) due to the following: • Leaching facility with standing liquid level at or above the invert pipe (per Town Code 360-20 h). You are ordered to repair or replace the septic system within two (2) years from the date you receive this notification. Failure to repair/replace the septic system within the deadline period will result in future enforcement action. PER ORDER OF T BOARD OF HEALTH s McKean, R.S., CHO Agent of the Board of Health I Q:\SEPTIC\Title V Inspection Report Letters MailingFailed or Needs Further Evaluation Letters\148 Megan Road Hyannis.doc f �THE Tp� Town of Barnstable RA"STAHL �A b 9 Inspectional Services Department rED MA'S� Public Health Division 200 Main Street, Hyannis MA 02601 Office: 508-862-4644 FAX: 508-790-6304 Thomas A.McKean,CHO Feb 6, 2007 Rev. 4/26/19 DEADLINES TO REPAIR FAILED SYSTEMS (Town Code §360-44 and Title V: 310 CMR 15.000) An "x" marked in the ❑ is the failure criteria and associated repair deadline 60 DAY DEADLINE CRITERIA ❑ Discharge or ponding of effluent to the surface of the ground ❑ Pumping more than 4 times during the last year not due to clogged or obstructed pipe. ❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool ❑ Structurally unsound septic tank or SAS ONE (1) YEAR DEADLINE CRITERIA ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation ❑ Any portion of the cesspool within a Zone 1 to a public well ❑ Any portion of a cesspool within 50 feet of a private water supply well with no acceptable water quality analysis. (This system passes if the water analysis indicates the well is free from pollution). TWO (2) YEAR DEADLINE CRITERIA ❑ Single.Cesspool - ❑ Any "conditionally passed systems" (broken cover, relocation of a pipe, relocation of a driveway due to H-10 components, etc) �II`Keaching facility with standing liquid level at or above the invert pipe (per Town Code §360-20 h) OTHER Repair deadline: Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc Commonwealth of Massachusetts O?/l- ac Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 148 Megan Road Property Address t Nancy Mouradian ` Owner Owner's Nam information is Hyannis Ma 02601 7/31/2019 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. Inspector Information /000 filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key.. 74 Beldan Lane Company Address Centerville Ma 02632 City/Town State Zip Code 774-248-4850 smjonestitle5@gmail.com, S14522 sean@smjonestitle5.com License Number B. Certification - I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. After conducting this inspection I have determined that the system: 1. ❑ Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ® Fails 7/31/2019 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 has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 ,*A, Commonwealth of Massachusetts Title 5 Official Inspection Form !� Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 148 Megan Road Property Address Nancy Mouradian Owner Owner's Name information is required for every Hyannis Ma 02601 7/31/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form is Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 148 Megan Road Property Address Nancy Mouradian Owner Owner's Name information is required for every Hyannis Ma 02601 7/31/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 16.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form F' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Megan Road V Property Address Nancy Mouradian Owner Owner's Name information is required for every Hyannis Ma 02601 7/31/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and.SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well**. Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 f Commonwealth of Massachusetts Title 5 Official Inspection Form �e Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Megan Road Property Address Nancy Mouradian Owner Owner's Name information is required for every Hyannis Ma 02601 7/31/2019 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ® ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than '/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 SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® ❑ The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a Y Y design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form �a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Megan Road Property Address Nancy Mouradian Owner Owner's Name information is required for every Hyannis Ma 02601 7/31/2019 page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered "yes"to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in 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)] t5insp.doc-rev.7/26/2018 Titte 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts 1 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 148 Megan Road Property Address Nancy Mouradian Owner Owner's Name information is required for every Hyannis Ma 02601 7/31/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 2 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 gpd Description: Number of current residents: 3 Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: current Date t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts �a Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments p 9 Y rY 6 148 Megan Road Property Address Nancy Mouradian Owner Owner's Name information is required for every Hyannis Ma 02601 7/31/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 Commonwealth of Massachusetts �9 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Megan Road Property Address Nancy Mouradian Owner Owner's Name information is required for every Hyannis Ma 02601 7/31/2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/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): Approximate age of all components, date installed (if known) and source of information: unknown Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 2 feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Joints In good condition, no leakage, vented through roof. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments t!` v% 148 Megan Road Property Address Nancy Mouradian Owner Owner's Name information is required for every Hyannis Ma 02601 7/31/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: 1.5 feet If Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 gallons Sludge depth: 5„ Distance from top of sludge to bottom of outlet tee or baffle 3' Scum thickness 2" Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" How were dimensions determined? Opened covers and took measurements Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. t5insp.doc•rev.712 612 01 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 148 Megan Road Property Address Nancy Mouradian Owner Owner's Name information is required for every Hyannis Ma 02601 7/31/2019 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap (locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 148 Megan Road Property Address Nancy Mouradian Owner Owners Name information is required for every Hyannis Ma 02601 7/31/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level: Alarm in 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 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert N/A 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.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form I,a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 4" 148 Megan Road Property Address Nancy Mouradian Owner Owner's Name information is required for every Hyannis Ma 02601 7/31/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 148 Megan Road Property Address Nancy Mouradian Owner Owner's Name information is required for every yH annis Ma 02601 7/31/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): leach pit was video inspected from tank and was found full of water within 2"of inlet pipe resulting in a failing inspection. 12. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth —top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): I t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments a 148 Megan Road Property Address Nancy Mouradian Owner Owners Name information is required for every Hyannis Ma 02601 7/31/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form la Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Megan Road Property Address Nancy Mouradian Owner Owner's Name information is required for every Hyannis Ma 02601 7/31/2019 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately Y � Q � a 3 r T� t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form b Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4' 148 Megan Road Property Address Nancy Mouradian Owner Owner's Name information is required for every Hyannis Ma 02601 7/31/2019 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ❑ Checked with local Board of Health -explain: ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater was not established Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7/2 612 0 1 8 Title 5 Official Inspection Form;Subsurface Sewage Disposal System•Page 17 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 148 Megan Road Property Address Nancy Mouradian Owner Owners Name information is required for every Hyannis Ma 02601 7/31/2019 page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or checked ® C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria) and 6 (Checklist) completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 18 of 18 AsBuilt Page 1 of 1 TOWN OF BARNSTABLE 'I;OCATION % ' CG%�` SEWAGE # N VILLAGE ASSESSOR'S VM AP & LOT/ INSTALLER'S NAME & PHONE NO. U J / / 6 :SEPTIC TANK CAPACITY , lEACHING FACILITYAtype (size) +�^� -No.OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER 15IIILDER OR OWNER G 1'�n-('-Y=d 421 DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: `nARIANCE GRANTED: Yes No �ry_n j� - t http://issgl2/intranet/propdata/prebuilt.aspx?mappar=291258&seq=1 8/19/2019 THE COMMONWEALTH OF MASSACHUSETTS BOARD F HEA T 1�...._-- - --- --------OF...... ....................... --- -- ------------ ................. S Appliration for Bispos l Works Toustrurtion Vamit � t Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal &1 System at / -cation:Addr / or lot No ..... "--- 1. . .. ------------- ----. ...`<.... ............... ...................................... Owne - Address W Installer Address / Q Type of Building Size Lot../..de. 4Z Sq. feet U Dwelling—No. of Bedrooms-________---� ___.Expansion Attic ( ' ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) Pa Other fixtures --------------- ------------- - W Design Flow........:.......15�_e................. per person per day. Total daily flow.....................................:------gallons. WSeptic Tank—Liquid capacityy�llons Length................ Width-----------.-.-- Diameter---------------- D th_--_-__-------- x Disposal Trench—No...........//..... ... W' h.. __ .... .. T to L i_ _______________ Total leaching area------ 0,s ft. Seepage Pit No......... C/ �------------- e t win et......._......------ Total leaching area------------------sq. ft. Z Other Distribution box ( ) C/ Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date---------------------- ............. Test Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water-.--__-_--_-_--_-----... w Test Pit No. 2................minutes per inch Depth of Test Pit..................... Depth to ground water------------------------ --------------------------------------------------------------------------------------------------------------------------------- -------------------------- O Description of Soil- --------------- - ••••--•-•--•----------•------•......---•- ----•---•-••-----•----------------------- •---•----- -- - -------- ---- ------- --- W ------------------------------ -------------------•------------•------------------------•--- _ U Nature of Repairs or Alterations—Answer when applicable.:_-_________________------------------ _ _ ____ ----•---------------------------------------------- --- ----------- --I--------------------- Agreement: The undersigned agrees to install the aforedescribed. Individual Sewage Disposal System in accordance with the provisions of Article 1I of the State Sanitary Code=The un rsined further agrees not to place t�l e system in operation until a Certificate of Compliance hasAbeenissuAbyt1Aoard_of h.Sig d. --•-•---- -----•- -•-------... � ------ Da Application -•------.2_ A lication Approved B •.6 � - - Date Application Disapproved for the following reasons:--------------- -...........------ ---------------------------------------------•-•-- ...--•------------_".�----------------------------------------------------------------------------------•------------------------------------------------------------------------------------------------- Date PermitNo......................................................... Issued-----/-.�-- / ?------------- ate f~� f f 4 G No...._Z.__ IT �.�. ............. THE COMMONWEALTH OF MASSACHUTSEETTS VrIL- BOARD OF HEAkL-Y ' ...............OF...... % ?i�................ .......................................... ) �� Appliration for BiipnsFal Works Tomitrurtion Prrmit :� 1 Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal System at: ........................ ation-Addr ---- s� � or Lot No. 1.fL....... �Cc.G W O ne... Address Installer Address J d Type of Building Size Lot_Dwelling ...Sq. feet U Dwelling—No. of Bedrooms------------ _`-------------------------Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ............................ No. of persons___-----__-_____--__--__-_ Showers ( ) — Cafeteria ( ) a' Other fixtures --•______________________________ --•--•----------------•-•-•-------------------•-----------•----------------------------------------•---- W Design Flow...............%_.................gallons per person per day. Total daily flow--------------------------------------------gallons. WSeptic Tank—Liquid capacity_ gallons Length................ Width---------------- Diameter------------- De 2th___-._-._.--. Disposal Trench—No.--...--•.--.._�.. W ,th_____ ___________ T-tad L 1. ....._........_ Total leaching area______ -sq. ft. x Seepage Pit No.- -j -rep h'blZiw to et Total leaching area sq. tt. Z Other Distribution box ( ) Dosing tank ) aPercolation Test Results Performed by-------------------------------------------------------------------------- Date---------------------------------------- a Test Pit No. 1----------------minutes per inch Depth of Test Pit-------------------- Depth to ground water._---___--__________._.. Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water_______________________. P4 ------••-•-------------------------•------------•-------------------•------•--•------•---.....------......................................................... Description of Soil---------- __:_______________ _____ ------------------------------------------------------------------------------------------ x � �------- - ----------------------------------------------------------------------------------------- W UNature of Repairs or Alterations—Answer wh n applicable------------------------------------------------------------------------------------------------ ---- --------------------------------------------------------------------- ..................................--------------------------------------------------------------------------------- Agreement: i The undersigned agrees to install the/aforedescribed Individual Sewage Disposal System in accordance with the provisions of Article XI of the State Sanitary Code—The un#ersigned further agrees not to place the system in operation until a Certificate of Compliance has been 'ssu d by h vboardd of h-'Tth 41 Signed !1 .�i/: ------------- ;_ •_- _� . e 6.-;e Application Approved By------........ !` i°- ' -" -f ,y 9AA- Date --- Application Disapproved for the following reasons________________________________________________________________________________ ---•--• Date PermitNo......................................................... Issued........................................................ Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEAL H f�� ........ , OF.... ��.GG'?.cc .......................................... (In if iraatr of 'nutphatta THIS IS T CERTIFY That the I dividu Sewage Disposal System constructed ( or Repaired ( ) by-----------•-----/� ...--_ -- •��-�'-'c"y > Installer- has been installed in accordance with the prs of Article XI of The State Sanitary Code as described in the application for Disposal Works Construction Permit No......................................... dated-----------------------------------............. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WI L FUN ION SATISFACTORY. DATE Inspector........../-------------------------------- --------------------------------- THE COMMONWEALTH OF MASSACHUSETTS �j BOARD7F HE.A�L�T�'�` V` ............OF...-..: G /.. .............. , No......................... FEE__z..--•-----....... Di voiiFal Porki nhfitr in r tit Permission islbQreby granted........... -----..----------------------------------------- to Construct r epair ( ) a ividual Sewage Disposal P. Sv em ,�/ -------- ------------------- ----- -------- /e Street as shown on the application for Disposal Works Construction Permit No--------------------- Dated___-_._________--___-____--_______-__----- -----------••-••-••---------••-••------•-----•-------•------- ----------------------------------------- Board of Health DATE................................................................................ FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS