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HomeMy WebLinkAbout0164 MEGAN ROAD - Health 164 MEGAN RD� A[�S 1 i k Commonwealth of Massachusetts G W Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Megan Road M ' Property Address Lori Baker Owner Owner's Name information is required for every Hyannis MA 02601 3-17-17 page. City/Town State Zip Code Date of Inspection ;, Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information s/# /aab3 filling out forms uuuumm�u on the computer, `���` q .�N OF tij use only the tab 1. Inspector. ��.�`y��'.• •' so,9��i� key to move your �y cursor-do not ��;' James D.Sears _�, JAMES :m= use the return key. Name of Inspector Capewide Enterprises t►/flr� II Company Name TRTIIF 'O'�`' " 153 Commercial Street ��,�S INSP�Cp��``��` Company Address Mashpee MA 02649 City/Town State Zip Code 508-477-8877 S1623 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 3-22-17 spector'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 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.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts G W Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Megan Road Property Address Lori Baker Owner Owner's Name information is required for every Hyannis MA 02601 3-17-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The system is a 1000 Gal. Tank and two pits. Note: Tank outlet and pit#1 outlet both have a zable filter. 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.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Megan Road Property Address Lori Baker Owner Owner's Name information is required for every Hyannis MA 02601 3-17-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)'are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form a a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Megan Road Property Address Lori Baker Owner Owner's Name information is required for every Hyannis MA 02601 3-17-17 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 Al/q ❑ ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in mmM=is less than 6" below invert or available volume is less than %day flow Pty' t5ins.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Megan Road Property Address Lori Baker Owner Owner's Name information is required for every Hyannis MA 02601 3-17-17 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area— IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts w v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Megan Road Property Address Lori Baker Owner Owner's Name information is required for every Hyannis MA 02601 3-17-17 page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ❑ ® Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ ® Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): NA Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17 Commonwealth of Massachusetts G W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Megan Road Property Address Lori Baker Owner Owner's Name information is required for every Hyannis MA 02601 3-17-17 page. City/Town State Zip Code Date of Inspection D. System Information Description: The system is a 1000 Gal. Tank and two pits. Number of current residents: NA Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes'® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage 2015-21,700Gal g ( y g (gpd)) 2016-21,700 Gal's Detail: Sump pump? ❑ Yes ® No Last date of occupancy: PresentDate 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ' M 164 Megan Road Property Address Lori Baker Owner Owner's Name information is required for every Hyannis MA 02601 3-17-17 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: NA 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Megan Road Property Address Lori Baker Owner Owner's Name information is required for every Hyannis MA 02601 3-17-17 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: NA Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 18"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.): Pipeing is 4" PVC SCH -40. Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 1000 Gal. Precast H-10 Sludge depth: 3° t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M ,•''y 164 Megan Road Property Address Lori Baker Owner Owner's Name information is required for every Hyannis MA 02601 3-17-17 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 27" Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 811 Distance from bottom of scum to bottom of outlet tee or baffle 17" How were dimensions determined? Asbuilt-Tape Sludge Judge 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 at working level. Tank and covers at 2" below grade. Inlet baffle, Outlet Tee/w a zable filter. No sign of leakage or overloading. 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 t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 17 Commonwealth of Massachusetts _ W Title 5 Official Inspection Form h Subsurface Sewage Disposal System Form -Not for Voluntary Assessments / M 164 Megan Road Property Address Lori Baker Owner Owner's Name information is required for every Hyannis MA 02601 3-17-17 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal El fiberglass El polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 15ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts uu w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M ,..°'r 164 Megan Road Property Address Lori Baker Owner Owner's Name information is required for every Hyannis MA 02601 3-17-17 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 No Box 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Megan Road Property Address Lori Baker Owner Owner's Name information is required for every Hyannis MA 02601 3-17-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ 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.): Leaching is two 1000 Gal.Precast pits. Pit# 1 and cover at 2" below grade. One line in, One line out w/tee and zable filter. 20"water in pit. Pit#2 and cover at 19" below grade. Pit is dry w/clean like new wall's. 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.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts v - Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 164 Megan Road Property Address Lori Baker Owner Owner's Name information is Hyannis MA 02601 3-17-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc,): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts u . Title 5 Official Inspection Form A s Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 Megan Road Property Address Lori Baker Owner Owner's Name information is required for every Hyannis MA 02601 3-17-17 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately ' S R WZ g_,n 30' -bgCK c� 3 g q o o O. 3 t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 I Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments ,M 164 Megan Road Property Address Lori Baker Owner Owner's Name information is Hyannis MA 02601 3-17-17 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells o N 25' 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: G W at 25'+ per town map's Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins.doc•rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 4. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 164 Megan Road Property Address Lori Baker Owner Owner's Name information is H annis MA 02601 3-17-17 required for every y page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information— Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins.doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 117 No. . D Oil Fee/O C/ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes ZIpprtcatton for �Digpogal i§pgtem Cow9tructton 30ermtt Application for a Permit to Construct( ) Repair(Upgrade( ) Abandon( ) ❑ Complete System Individual Components Location Address or Lot No. Ile"141e _496orp'le- Owner's Name,Address,and Tel.No. g ®4P— 'Qra6'v L07-y( �r+�� /' ,jya�E-e .�.d f !G �7e Assessor's Map/Parcel '� 0 Installe 's Name,Address and Tel.No ¢PI��'��'� > Designer's Name,Address and Tel.No. Y/ Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) '00�-1/�rB oce IA Date last inspected: i ! 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. Signed Date Application Approved by 44 12 Date / Application Disapproved b kA Date for the following reasons Permit No. ]� 3 y Date Issued t "No. Fee O tJ THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: _es Yes -PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS application for 0igPoga1 *pgtem ComAructton Vermtt Application for a Permit to Construct O Repair(Upgrade O Abandon O ❑ Complete System�Individual Components Location Address or Lot No.1,5r <f , Owner's Name,Address,and Tel.No. ;7flZ010 LOT�/( �`'�-94 s� oP• ,j'y°s�`e /��o i . /! Assessor's Map/Parcel �5e4 Installer's Name,Address and Tel.No Wa���a•��i Af Designer's Name,Address and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder ( ) Other Type of Building.,f'i� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title 1 Size of Septic Tank Type of S.A.S. Description of Soil Nature eoof:Repairs or Alterations(Answer when applicable) �T�•f'/.y/F oc+74/e tg Date last inspected: 8z�l _ 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. Signed a Date Application Approved by � tA Date Application Disapproved b Date ` R.� for the following reasons Permit No. 3�2 Date Issued 9/ THE COMMONWEALTH OF MASSACHUSETTS Q lJ � ,22_ BARNSTABLE,MASSACHUSETTS 7 Certificate of Comphance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed ( ) Repaired (t_� Upgraded ( ) Abandoned( )by �rF�/ ...►^�-mar.�i:� /3 L'c�►ni ss at ¢_-Z �/ c.�i�.�✓m.. 'f' has been constructed in accordance with the provisions of Title 5 and the for Disposal-Sy em Construction Permit No. dated /21 11, Installer ,d �' Designer #bedrooms rl I '�— Approved design flow A gpd The issuance of this permit shall not be construed as a guarantee that the syst t�tfttne ton as designed. Date �O l �� Inspectra(r e -------------------------------------------- No. ;�.o it , 3 a 2-- Fee /du THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE, MASSACHUSETTS 0i po.5al *_ p9tem Con5tructfon Vermtt Permission is hereby granted to Construct ( ) Repair ( Upgrade ( ) Abandon ( ) System located at //_ems ,�1�/s•� r, / /ice,��,�'c and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to comply with Title S and the following local provisions or special conditions. Provided: Construction ust be completed within three years of the date of this Date 1 / 6 / Approved by I F 3 f 0 �oF r� Town of Barnstable �r� Barnstable rP�~ Regulatory Services Department ;&lcaCftv i IIAMSTABLE, C� MASS $ Public Health Division i639, `� m ATF0 MAI�` 200 Main Street, Hyannis MA 02601 2007 Office: 508-862-4644 Thomas F.Geiler,Director FAX: 508-790-6304" Thomas A.McKean,CHO CERTIFIED MAIL # 7011 0470 0001 4525 7635 September 8, 2011 Mr Steven Morin 164 Megan Road Hyannis, MA 02601 ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5 1301 Old Post The septic system located at 164 Megan Rd., Hyannis, MA was last inspected on 8/15/ 2011,by Mark L. White, a certified septic inspector for the State of Massachusetts. The inspection of the septic system showed that the system "Conditionally Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following: • Probable backup of sewage into facility or system component due to over loaded or clogged SAS. You are ordered to repair or replace the septic system within sixty (60) days 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 THE BO RD OF HEALTH Thomas McKean, R.S., CHO Agent of the Board of Health I Q:\SEPTIC\Letters Septic Inspection Failures\TEMPLATEI.doc Commonwealth of Massachusetts.. Form 8 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 164 MEGAN RD Property Address_ STEVE MORIN Owner Owner's Name information is required for every HYANNIS MA 02601 AUGUST 15 2011 page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. please see completeness checklist at the end of the form. Important:when A. General Information filling out forms on the computer, Il..�n lei use only the tab 1. Inspector: f key to move your cursor-do not MARK L WHITE use the return key. Name of Inspector A.B. CANCO � Co mpany Name 350 RT 28 _........ . ... -- - -- -- ---- - Company Address WEST YARMOUTH MA --- 02673 Cityrrown State Zip Code — -__ 508-775-2820 S-13381 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 sib sewage disposal systems. I am a DEEP approved system inspector pursuant to Se,, tion 1 �i40 oP Title 5 (310 CIVIR 15.000).The system: v% `��ityi 0�Uq rrrt zz ❑ Passes a Conditionally Passes . O-;'• IY3��� G;-fir .. WHIITE r"a ❑ deeds Further Evaluation by the Focal Approving Authority �,: > : No.S13381 y i � ��" 1 N Sp��'``O��� �'n _ AUGUST 15 2011 ���i�f��jijiuuruu►�}�`_�....._ '.. .. nspector'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 DER 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 facture under the same or different conditions of use. G ins•I t11C Title 5 Qfficiai Inspe-an Fo m:Subsurface Sewage oisposal System•Psge 1 of 29 Olt I f Commonwealth of Massachusetts --- : -- Title -w ?l Subsurface Sewage Disposal System For-Not for Voluntary Assessments 164 MEGAN RD Pro _.p..erty__Ad---dress - --- ------------------ --- - STEVE MORIN Owner - Owner's Name information is required for every HYANNIS MA 02601 AUGUST 15 2011 page. City/Tvwn State Zip Code mate of In ction Inspection results must be submitted on this form.Inspection forms may not be altered in any Way. Tease see completeness checklist at the end of the form. Important,When A. General information filling out forms on the computer, use only the tab 1. inspector: key to move your cursor-do not MARK L WRITE use the return key. Name of Inspector A.B. CANCO - -- — --------— ------ ry Company Name 350 RT 28 —_ Company Address WEST YARMOUTH MA 02673 City/Town Stag Zip Code 508-775-2820 S-13381 Telephone Number License Number 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 16.304 exist. Any failure criteria not evaluated are indicated below. Comments: 13) System Conditionally Passes: n 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. t5ins•11l10 T"dle 5 Official Inspsdion Fr1nn:Subsurface S�riage Disposal System•Page 2 of 29 I Commonwealth of Massachuseft Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 164 MEGAN RD --Property Address STEVE MORIN Owner Owner's Name information is required for every HYANNIS MA 02601 AUGUST 15-12. 01-1-11--l—..... page. City/Town State 7jp Code Da te-o-f-I-n.spedio.n Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important-When A. General Information filling out forms on the computer, use only the tab I Inspector: key to move your cursor-do not MARK L WHITE use the return Name of Inspector key. A.B. CANCO Company Name —'- 350 RT 28 Alf— Company Address WEST YARMOUTH MA 2673 --------- 0 City/Town State Zip Code 508-775-2820 5-1-3381 Telephone Number License Number 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 exffl tration 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. El Y ENS N ND (Explain below), B. Certification (cont.) B) System Conditionally Passes(cont.): t5ins-11/10 -'ale 5 Otifc al Inspection Form Subsurface Sewage Disposal System-Page 3 o.,29 Commonwealth of Massachusetts M Title 5 OfficialInspection Subsurface Sewage Disposal System Form a Not for Voluntary Assessments 164 MEGAN RD Property Address STEVE MORIN Owner Owner's Name — --------- __....... .............. _....._.._.._..--- ---.- information is required for every HYANNIS MA 02601 AUGUST 15 2011 page. Cityfrown 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. lmpoftnt.when A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not MARK L WHITE use the return ----...._-.--.._...._. .._ .. key. Name of Inspector A-B. CANCO Company Name 360 RT 28 Company Address WEST YARMOUTH MA ----- 02673 City/Town ------------ State ------------ Zip Code ------- 508 775-2820 5-13381 Telephone Number License Number ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipets)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): 0 broken pipets)are replaced C Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y El N D ND(Explain below): ❑ distribution box is leveled or replaced 17 Y 0 N D ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipets)are replaced Z Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y d N ❑ ND(Explain below): t5ins•11/10 Titie 5 Official Inspo0on Form:subsufface sewage Disposal System-Pave 4 of 29 Commonwealth of Massachusetts Title a - - Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 MEGAN RD Property Address STEVE MORIN Owner Owner's Na ------- --_-- ---_--------_........._.......... me information is required for every HYANNIS _- _.__. MA_ 02601 AUGUST 15 2011 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 fors. Important:When A. General Information filling out forms on the computer, use only the tab 1 Inspector: key to move your cursor-do not MARK L WHITE use the retain ------------------ -...--- ......... key. Name of Inspector A.B. CANCO Company Name 350 RT 28 Company Address WEST YARMOUTH MA 02573 Citylrown State Zip Code 508-775-2820 S-13381 Telephone Number License Number 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 wealth determines in accordance with 310 CMR 15.303('i)(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 B. Certification (cost.) 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: t5ins 11/1p Title 6 Offiaal lnspec-Gon Form:Subsurfne Sewage Disposal System-Page 5 of 29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 MEGAN RD Property Address STEVE MORIN Owner Owner's Name information is required for every HYANNIS T — MA 02601 AUGUST 15 2011 page. CityfTown 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 and of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not MARK L WHITE use the return _..._.._ .._...... -- ------------- — - ..... ......... key. Name of inspector A.B. CANCO _ Company game 350 RT 28 Company Address WEST YARMOUTH MA 02673 City(rown - — State --- — Zip Code 508-775-2820 S-13381 Teiephone Number Li�ngetumber ❑ 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 UEP certified laboratory, for fecal coliforrn 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: t5in •9,!;� Tale 5 ofn�,v rrtspevAion form:Su!nvrrace sewage Drspc at Syst m•sac,:5 of%3 Commonwealth of Massachusetts T"fle 5 Official sl Subsurface Sewage Disposal System Form Not for Voluntary Assessments 4 ^- 164 MEGAN RD Property Address -. ..... STEVE MORIN Owner - - ------ --_..__ ..____- _. __.__. _ ---------.._. _ . _ Owner's Name information is required for every HYANNIS ``MA 02601 AUGUST 15 2011 page. Citylrown 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 and of the form. Important:When A. General information filling out forms on the computer, use only the tat: 1. Inspector: key to move your cursor-do not MARK L WHITE use the return key, Name of inspector A.B. CANCO Company Name 350 RT 28 Company Address WEST YARMOUTH MA 02673 ._ _ __.-- _ ..._.... _ CitylTown State ,Zip Code 508-775-2820 _ _ 5-13381_ Telephone Number License Number ®) 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 El ® Liquid depth in cesspool is less than 6"below invert or available volume is less than '/2 day flow B. 'Certification (font.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: D Any portion of the SAS, cesspool or privy is below high ground water elevation. El N 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. t5ns-11/10 Title 5 Mcial Inspor n corm:Su9aurfece Sewage Disposal System•Page 7 of 29 Commonwealth of Massachusetts Title 5 Official Inspect'on Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 164 MEGAN RD Prop"Address STEVE MORIN ........... ------ Owner Owner's Name information is required for every HYANNIS MA 02601 AUGUST 15 2011 page. Cky f6iirl-------------- State-*' '' Zip Code,-,--, 'Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1 Inspector: key to move your cursor-do not MARK L WHITE use the return Name of Inspector key. A.B. CANCO VQ Company Name 350 RT 28 Company Address WEST YARMOUTH MA 02673 City/Town State Zip Code 508-775-2820 S-13381 telephone Number- License Number 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.) (7 1XI The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. n nX The system Lails. 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 TLW 5 cttnw 111spec6or Form",SuDsullace Sewage Disposal System-Page 8 kx,29 Commonwealth of Massachusetts Title 5 Offlocial Inspection Form Subsurface Sewage Disposal System Form m Not for Voluntary Assessments 164 MEGAN RD Property r ess STEVE MORIN Owner Owner's Name information is required for every HYANNIS ------ M,A., 026.0,1--------- AUGUST 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. Imponant:when A filling out forms General Information on the computer, use only the tab 1 Inspector: key to move your cursor-do not MARK L WHITE use the return Name of.Inspector key. AR CANCO Company Name 35ORT28 Company Address WEST YARMOUTH MIA 02673 City/Town state Zip Code 508-775-2820 S-1 3381 Telephone Number License Number 0 0 the system is located in a nitrogen sensitive area(interim Wellhead Protection Area—WPA) or a mapped Zone 11 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. 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? ❑ Fx1 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 Cl 2 available note as N/A)N/A 0 0 Was the facility or dwelling inspected for signs of sewage back up? nx o Was the site inspected for signs of break out? t5ins-11hO Titie 5 Qffiaal inspection Form:Subsurface Sewage Disposal System-Page 9 of 29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 164 MEGAN RD ................ ­."�I——------------ Property Address STEVE MORIN ------ - ------ owner Owner's Name information is required for every HYANNIS MA 02601 AUGUST 15.20.11. page. City/Town state Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1 Inspector: key to move your cursor-do not MARK L WHITE use the return Name of Inspector key. A.B. CANCO vQ Company Name 350 RT 28 Company Address ram WEST YARMOUTH MA 02673 City[Town State Zip Code 508-775-2820 S-13381 .. . ............. Telephone Number License Number ❑ 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: 2 ❑ Existing information. For example, a plan at the Board of Health. Z 0 Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15302(5)] D. System Information Residential Flow Conditions. UNK 2 Number of bedrooms(design): Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): UNK True 5 0friciai lrsp®dion Form:Subsurface Sewage Disposal System-P898 10 0 29 Commonwealth of Massachusetts . - - Title Official t a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 164 MEGAN RD Property Address _ — -- -- STEVE MORIN Owner .... .. . ..... ... ..... . . _...._. ..._ _...._ .... -.. _...____._. ...---- --------_. _........ ....:.. -_.. Owner's Name information is required for every HYANNIS_- _...............:._..__.._-._. -- MA_____ 02601 AUGUST 15 2011 _ page. City/Town state Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. general Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not MARK L WHITE _ use the return -------- --- key- Name of Inspector A.B. CANCO Company Name 350 RT 28 Company Address , » WEST YARMOUTH _ MA -- 02673 City/Town State Zip Code 508-775-2820 _ _ -- —__—_-- S-13381 __._..__.__... Telephone Number license Number D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? Yes No Is laundry on a separate sewage system?[if yes separate inspection required] d Yes ❑ No Laundry system inspected? ❑ Yes ❑ No Seasonal use? Q Yes ❑ No 00 --62 Water meter readings, if available(last 2 years usage(gpd)): 2 2009010-6200 t5ins,1 iJ1D Tdie 5 Offval Inspection Form:Subsurface Sewage Disposal System-Page 11 of 29 Commonwealth of Massachusetts Title 5 Official Inspection Form - sI Subsurface Sewage Disposal System Form Not for Voluntary Assessments 164 MEGAN RD Property Address STEVE MORIN Corner — -------...__._-......._ .....,......_........_...___.._.._--------- Owner's Name information is YANNIS MA 02601 AUGUST 15 2011 H requiredfor every _.m...T__._______-..._:.__..._.........�.:.___.....-.----.._...__._---....----........ page. City/town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way_Please see completeness checklist at the end of the form. Important,When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not MARK L WHITE use the return ----- ----- ...............___..._ .,.. _._.... ......._....... . _ ___-•---------------- key. Name of Inspector A.B. CANCO � Company Name 35o RT 28 Company Address WEST YARMOUTH - MA 02673 City/Town state —_ _..._.-.....___._._....__. • Zip Cede 508-775-2820 S-13381 Telephone Number License Number Details _ C7 ❑ Sump pump? YesNo Last date of occupancy: current Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15. 03): .------_.___.____-.__.. _ .... Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): M— 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-11110 Title 5 Official lnspwCtion Form:Subsurface Sewage Disposal System•Page 12 of 29 Commonwealth of Massachusetts Title 5 Officiali w Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 164 MEGAN RD Property Address STEVE MORIN Owner — -- — — ---�._�—._...-.__..,...- .....,.. . . ... , Owner's Name information is required for every HYANNIS MA 02601 AUGUST 15 2011 page. City/Town State. Zip Code Date of Inspection Inspection results mast be submitted on this form. Inspection forms may not be altered :n any way. Please see completeness checklist at the end of the form. Important:when A. Genera! Information filling out forms on the oomputer, use only the tab 1 inspector: key to move your cursor-do not MARK L WHITE use the return key. dame of Inspector A.B. CRNC© Company Name 350 RT 28 Company Address WEST YARMOUTH — — — MA — 02673 City/Town State Zip Code 508-775-2820 5-13381 Telephone Number License Plumber D. System Information (cons.) Last date of occupancyluse: __- Date Other(describe below): General Information Pumping Records: Source of information: BOARD cF HEALTH Was system pumped as part of the inspection? ❑ Yes n No If yes, volume pumped: — — ---------------_.__. ..____.__._.. _.. . gallons How was quantity pumped determined? Reason for pumping: __..._ Type of System: t5ins•11110' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 29 Commonwealth of Massachusetts Title 5 Official Inspection Form m Subsurface Sewage Disposal System Form -Not for Voluntary Assess, ents 164 MEGAN RD Property Address STEVE MORIN Owner r7i Name information is required for every HYANNIS iA 02601 AUGUST 152011 page'l City/Irown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important.,When A. General Information filling out forms on the computer, use only the tab 1. Inspector, key to move your cursor-do not MARK L WHITE use the return key. Name of Inspector A.E. CANCO Company Name 350 RT 28 Company Addr ens WEST YARMOUTH MA 02673 Cityrrown State Zip Code 508-775-2820 S-13381 Telephone Number License Number 07 Septic tank, distribution box, soil absorption system 0 Single cesspool 11 Overflow cesspool 0 Privy El Shared system(yes or no)(if yes, attach previous inspection records, if any) 0 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 0 "right tank. Attach a copy of the DEP approval. 0 Other(describe): D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: U N K Were sewage odors detected when arriving at the site? 0 Yes FX1 No Title 5 Official Inspedion Form;Subsurface sewage Disposal Systein-Page 14 of 29 Commonwealth of Massachusetts idal Inspection Form Title 5 un i Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ------- 164 MEGAN FAD ........... 0*rolp-rty-Addres--s- STEVE MORIN Owner Owner's Name information is required for every HYANNIS MA 02601 AUGUST 15 2011 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:Men A. General Information filling out forms on the computer, use only the tab 1 Inspector: key to move your cursor-do not MARK L WHITE use the return key. Name of Inspector A.B. CALICO —------ Company Name 350 RT 28 Company- ',-Address - WEST YARMOUTH .. .... MA 02673 State City/Town Zip Code 508-775-2820 S-13381 ........ Telephone Number License Number Building Sewer(locate on site plan): 15 INCHES Depth below grade: feet Material of construction: cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 6 INCHES Depth below grade: Material of construction: 23 concrete 11 metal ❑fiberglass El polyethylene C1 other(explain) t5ins•11 1 110 Yiiie5 official inspw%on Form:Suteur(ace Sewage 040saf Systeft, Page 15d29 Commonwealth of Massachusetts Title q Official t r Sewage ewage Disposal System Form-Not for Voluntary Assessments 164 MEGAN RD Property Address STEVE MORIN ---- -.._—_.._....,_._- ... .. _.... Owner owner's Name information is. MA 02601 AUGUST 15 2011 required for every HYANNI -__,,_•._-- _-- -------- ___.._... page. CityRowri state Zip Code date of Inspection Inspection results must be submitted on this form. inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:when A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not MARK L WHITE - useme return —___...._. . _. __..----- __.._..-- ---_._.._...............__._ key. Name of Inspector A.B. CANCO -----_ --- ---- Company Name 350 RT 28 ---___._.-- Company Address WEST YARMOUTH MA 42673 - ----._. City/Town state Zip Code 508-775-2820 ..._.__— __ - S-13389._., Telephone Number License Number If tank is metal, list age: years. ❑Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Yes No Dimensions: - ........ 41NCHES Sludge depth: ._..------- ®o System Information (cont.) Septic'Dank(cont.) Distance from top of sludge to bottom of outlet tee or baffle FEET ---- -- - 2 1NCHES Scum thickness 10 INCHES Distance from top of scum to top of outlet tee or bade _------ __.__- Distance from bottom of scum to bottom of outlet tee or baffle 16 INCHES --- - -- SLUDGE JUDGE, TAPE How were dimensions determined? MEASURE t5ins•11/10 Title 5 official Insp rion Form Subsurface Sewage Disposal System,Page 16 6129 Commonwealth of Massachusetts Title 5 Official Inspection Form 8 Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Owner 6Wn—e—csWzime-'­ 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,Men A. General Information filling out forms on the computer, use only the tab Inspector: key to move Your cursor-do not MARK L WHITE Use the return key Name of Inspector A.B. CANCO Company Name Company Address WEST YARMOUTH MA 02673 Zip Code Telephone Number License Number Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): � Grease Trap(locate onsite plan): Depth below grade: feet -'-------'-'---------- Material ofconstruction: ' 13noncrete El meta/ []fiberglass 0 polyethylene []other(explain): --_------ -...___-__-- ' Dimensions: Scum thickness ------------�---- m�oo���v�m m�o���*x��^o�zou�mm'�enm2o �" `,vm ' � Commonwealth of Massachusetts _- Title III Inspection Form -- Subsurface Sewage Disposal Systems Form 6 Not for Voluntary Assessments 164 MEGAN R_O Property Address STEVE MORIN -- Owner Oirmer's information is is HYANNiS MA 02601 AUGUST 15 2011 required for every _._ page. City5own - 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 Aa General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not MARK L WHITE use the return key. Name of Inspector A.B. CANCO - -- �, � Company Name 350 RT 28 _ _..___ __._...... Company Address WEST YARMOUTH _ MA 02673 City/Town State Zip Code - ~- 508-775-2820 S-13381 �..._._.. Tele hone Number License Number 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 D. System Information (cons.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete C3 metal ❑fiberglass ® polyethylene 0 other(explain): t5ins•11/10 Tiit6 5 OfFc ai irspedion Form:Subsurface Se:age Oisposaf System•Page 18 of 29 Commonwealth of Massachusetts Title 5 Official Inspection Form � Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Property 164 MEGAN RD Address STEVE MORIN Ownerowner's Name information is required for every HYANNIS MA 02601 AUGUST 15 20-l'.1----.. 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:WhenGeneral Information filling out forms on the computer, use only the tab 1 Inspector: key to move your cursor-do not MARK L WHITE use the return key. Name of Inspector A.B. CANCO v uwr Company Na I me---- 350 RT 28 Company Address WESTYARMOUTH MA 02673 State Zip Code 508-775-2820 S-13381 — -........ -------- Telephone Number License Number Dimensions, Capacity: gallons' Design Flow, gallons per day Alarm present: F Yes 0 No Alarm level: Alarm in working order: 0 Yes 11 No Date of last pumping: Date Comments (condition of alarm and float Switches, etc.): Attach copy of current pumping contract(required). is copy attached? 0 Yes [I No' D. System Information (cont.) Trfi'o 5 0"frW'ia2 Inspecdon Form:subsurface sew&p 0,*-Sw5a)syjFlhegr-Page 19 of 29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Prop"Address Owner information i's page, Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Insp ction fo s may not be altei in any way. Please see completeness checklist at the end of the form. Important.,When A. General Information filling out forms on the computer, use only the tab 1 Inspector key to move your use the return key. Name of Inspector A.B. CANCO Company Address Cityrrown State Zip Code Telephone Number License Number Distribution Box(if-present must be opened)(locate on site plan): Depth of liquid level above outlet invert NO DISTRIBUTION BOX 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 om site plan): ' 0 Yes [] No Pun�poinvvorh�gqndmr . . Fl Alarms invvorknQ onder � �� Yes 0 No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): TO-,5 Official mpmc�o"rmmnubmmaceoew"onwP0m/SYS10m'pww20*29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 164 MEGAN RD Oir-opirt Address STEVE MORIN'. Owner Owner's Name information is MA 02601 AUGUST 15 2011 required for every HYANNIS 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 filling out formsGeneral Information on the computer, use only the tab 1 inspector. key to move your cursor-do not MARK L WHITE ........ use the return key. Name of Inspector A.B. CANCO ------ to Company Name 350 RT 28 Company Address WEST YARMOUTH MA 02673 Cityrrown State Zip Code 508-775-2820 S-13381 iiie-phone Number' License Number Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: .......... D. System Information (cont.) Type: 2--6X6 LEACH leaching pits number: PITS ----------- t5ins-11110 TIM 5 Official lnspediaa ktrnm Subsurface Sewage Disposai syst€m,Pago 21 of 29 Commonwealth of Massachusetts Title Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �u 164 MEGAN RQ Property Address STEVE MORIN ------------ Owner Owner's Name information is ,/jq 02601 AUGUST 15 2011 required for every HYANNIS ------ page. City/Town" - State Zip Code Date of Inspection Inspection results must be submitted on this form.inspection forms may not to altered in any way. Please see completeness checklist at the end of the form. Important:when A. General Information filling out forms on the computer, use only the tab 1. inspector: key to move your cursor-do not MARK L WHITE use the return key. Name of Inspector CANCO Company _ _ - - Company Name.,, 350 RT 28 Company Address WEST YARMOUTH .__ .. ...—_......_ 02673 City/Town State Zip Code 503-775-2820 S-13381 r Telephone Number License Number ❑ leaching chambers number: ❑ 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.): 1 PIT IS FULL AND LEACHING INTO THE 2ND PIT WHICH HAS 12 INCHES OF LIQUID IN IT t5ins•19/10 T tB 5 OftAsl inspWlon Form,.Subsurf=e Sewage Disposal$yatem•P2Ge 22 of 29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 164 MEGAN RD ...... i*o'peirty Address- STEVE MORIN Owner 66W�`Naii�e'­ information is MA 02601 AUGUST 15 2011 required for every dYANNIS page. Cityrrown State ZIP Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1 Inspector: key to move your cursor-do not MARK L WHITE ...... use the return key. Name of Inspector A.B. CANCO Company Name 350 RT 28 Company Address WEST YARMOUTH MA- 02673 state Zip Code 508-775-2820 S-13381 Telephone Number License Number 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 D Yes C3 No D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5m•11/10 Talc 5 Official Impection Fom Subsurface Sewage Dis -at System•Page 2S Of 29 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 164 MEGAN RD ------- -------------- Property Address _... STEVE MORIN Owner Owner's Name information is required for every HYANNIS MA 02601 AUGUST 15 2011 page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General information filling out forms on the computer, use only the tab 1 Inspector: key to move your cursor-do not MARK L WHITE use the return key. Name of Inspector A.B. CANCO 35.0_.'RT_28 Company Address WEST YARMOUTH MA 02673 Gityllown State Zip Code 508-775-2820 S-13381 Telephone Number License Number 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-11110 rfac 5 Off[CW h1SP&GW'1 Form:SUbSUftCO SG age D!WS&1 SYSt&M•P,4W24 of Commonwealth of Massachuseft% Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Owner Ow.ner's Name page. City/Town State Zip Code Date of Inspection inspection results must be submitted on this form. Inspection forms may not be aftered in any way. Please see completeness checklist at the end of the form. Impoftnt:When A. General Information filling out forms on the computer, use only the tab Inspector key to move your use the return key Name of Inspector A.S. CANCO Company Name Company Address MST YARMOUTH MA 02673 Cityrrown State Zip Code Telephone Number License Number D. System Information (cont.) Sketch OfSewage Disposal ' : ProvidmmviewCfthewevvoQe 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: 9 hand-sketch inthe area below D drawing attached separately ' ^ � | Commonwealth of Massachusetts : - Titler - Subsurface Sewage Disposal System Foffn-Not for Voluntary Assessments :mi l 164 MEGAN RC} Property Address STEVE M®RIN — Owner UwRee's ttlamE _ - information is �{YAi�ItVIS MA 02601 AUGUST_15 2011 --_ required for every - - page- Cityrtown state Zip Code Date of Inspection inspection results must be submitted on this fora.inspection forms may not be erred in any moray. please see completeness checklist at the egad of the form. important*when A. General Information filling out forms on the oomputer, use only the tab 1. Inspector key to move your cursor-do not MARK L WHITE use the return .dame of Inspector key. Company name 350 RT 28 Cornpany Address MA WEST YARMOUTI S-- _ _..__�. - - ....---- ------- -..-- 02673 CitylTown State Zip Cote 508-775-2820 5-13381 Telephone t.-urnber License.dumber fi 4 - ` f ® C 9 0 Re F e 5 C'tF 2j tnspe ion Form'SuCsuefsce Sewage Disposal System•Page 26 of 29 Commonwealth of Massachusetts ._. ,.,.NO Title 5 Official Inspection Form Subsurface Sewage Disposal System Farm-Not for Voluntary Assessments 164 MEGAN RD - Property Address STEVE MORIN Owner's Name Owner _._.....- ----.........--- information is MA 02601 AUGUST 15 2011 required for every HYANNIS _- page, Cityfrown _ ---.- State Zip Code Date of inspection Inspection results must be submitted on this font. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the forth. Important_when A. General Information filling out forms on the computer, use only the tab Inspector: key to move your cursor-do not MARK L WHITE usethe return --...... ----..._...... ----.._.._.....___._._... ----- key Name of Inspector Q A.B. CANCO Company Name 350 RT 28 Company Address WESTYARMOUTH _ _._ MA_..._..__. 02673 Cityrrown State Zip Code�^ 508-775-2820 S-13381 ___.. "telephone Number License Number D. System Information (cont.) Site Exam: Check Slope Surface water D Check cellar Shallow wells Estimated depth to high ground water: 25.3 feetfeet - — 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: 17 Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: t5ins•11/10 t*5 O rc iW In P,0--A:n Fa1M Sub5U faca Sewage D spo-ml System•?age 27 a1 9 Commonwealth of Massachusetts its 5 Official Inspection Form Subsurface Sewage Disposal System Form,Not for Voluntary Assessments 164 MEGAN RD Property Address STEVE MORIN -------- ........... Owner 6wn'er"sNa_me__ information is required for every HYANNIS MA 02601 AUGUST 15,20,11 page. City/Town State Zip Code Date of Inspection inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1 Inspector. key to move your cursor-do not MARK L WHITE use the return key. Name of Inspector A.B. CANCO ------- Company Name 350 RT-28 ........... Company Address WEST YARMOUTH MA_­­­.______­_..__­­ 02673 City/Town State — Zip Code 508-775-282 0 S-13381 'Telephone Plumber License Number 1_1 Checked with local excavators, installers-(attach documentation) nX Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS Well Data Well AIW 230 25.3 Barnstable Health IGS &elevation 25 feet Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins-11110 -rj!j9 5 Qffr,,aj lnsp94i^^Form'subsurface sewage L)tsposaj systam-Pago 28 OLU9 Commonwealth of Massachusetts 0"W"cial Inspection Fom Title u r Subsurface Sewage Disposal System Form Not for Voluntary Assessments 164 MEGAN RD Property­Addres'S­­------- STEVE MORIN Owner owner's Name information is required for every HYANNIS MA 02601 AUGUST 15 2011 page. dW/-i;o—wn ----­--'--'---- 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 filling out forms A. General Information on the computer, use only the tab 1 Inspector key to move your cursor-do not MARK L MITE use the return key. Name of Inspector A.B. CANCO .......... Company Name 350 RT 28 Company Address WEST YARMOUTH MA —----- 02673 CityfTown State Zip Code 508-775-2820 S-13381 Telephone Numbe-r- License Number E. Report Completeness Checklist Z inspection Summary: A, B, C, D,or E checked 0 Inspection Summary D (System Failure Criteria Applicable to All Systems)completed 9 System Information— Estimated depth to high groundwater 9 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins-i1110 T-Itic offml Inspection Form:Sulnurf�Sewage Dispposaj Sy=tem•Page 29 of 29 t V� COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS a DEPARTMENT OF ENVIRONME NTAL PROTECTION 350 MAIN STREET & WEST YARMOUTH,MA 508-775-2800 TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 164 MEGAN ROAD HYANNIS,MA 02601 Owner's Name: BRUCE HERTZ Owner's Address: 164 M.E'GAN ROAD - HYANNIS,MA 02601 Date of Inspection MARCH 1,2001 Name of Inspector:(please print) JAMES D. SEARS Company Name: A&B Canco Mailing Address: 350.Main Street West Yarmouth,MA 02673 Telephone Number: 508-775-2800 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 Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �Zj e Date: 3-1-01 The system inspector sha 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 tot he buyer,if applicable,and the approving authority. Notes and Comments ****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 1 Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 164 MEGAN ROAD HYANNIS,MA 02601 Owner: HERTZ,BRUCE Date of Inspection: MARCH 1,2001 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D 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 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: N/A _ 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 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: 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: I Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) Property Address: 164 MEGAN ROAD HYANNIS,MA 02601 Owner: HERTZ,BRUCE Date of Inspection: MARCH 1,2001 C. Further Evaluation is Required by the Board of Health: N/A _ 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(i)(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 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 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: Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(CONTINUED) Property Address: 164 MEGAN ROAD HYANNIS MA 02601 Owner: HERTZ,BRUCE Date of Inspection: MARCH 1,2001 D. System Failure Criteria applicable to all systems: N/A You must indicate"yes"or"no"to each of the following for all inspections: Yes No 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 N/A Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in pit is less than 6"below invert or available volume is less than 'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation N/A Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply N/A Any portion of a cesspool or privy is within a Zone 1 of a public well N/A Any portion of a cesspool or privy is within 50 feet of a private water supply well N/A 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 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 Systems: N/A To be considered a large system the system must service 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 is failed. The owner or operator of any large system considered a significant II 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. Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 164 MEGAN ROAD HYANNIS MA 02601 Owner: HERTZ,BRUCE Date of Inspection: MARCH 1,2001 Check if the following have been done. You must indicate"yes"or"no"as to each of the following Yes No X Pumping information was provided by the owner,occupant,or Board of Health 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? X Were as built plans of the system obtained and examined?(If they were not available note as N/A) X Was the facility or dwelling inspected for signs of sewage back up? X Was the site inspected for signs of break out? X Were all system components,excluding the SAS,located on site? 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 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)has been determined based on: Yes No X Existing information. For example,a plan at the Board of Health. X 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)] Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 164 MEGAN ROAD HYANNIS,MA 02601 Owner: HERTZ,BRUCE Date of Inspection: MARCH 1,2001 FLOW CONDITIONS RESIDENTIAL 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 Number of current residents: 2 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): YES Seasonal use(yes or no): NO Water meter readings,if available(last 2 years usage(gpd)): 1999 5800 CU.FT./2000 2400 CU.FT. Sump pump(yes or no) NO Last date of occupancy: N/A COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): Basis of design flow(seats/persons/sqft,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 Source of information: 1992 Was system pumped as part of the inspection(yes or no): NO If yes,volume pumped: gallons—How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank, 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) Tight tank Attach copy of the DEP approval Other(describe): Approximate age of all components,date installed(if known)and source of information: AGE OF SYSTEM AROUND 1974.NEW PIT 1992 PERMIT#92-231 Were sewage odors detected when arriving at the site(yes or no): NO Title 5 Inspection Form 6/15/2000 6 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 164 MEGAN ROAD HYANNIS,MA 02601 Owner: HERTZ,BRUCE Date of Inspection: MARCH 1,2001 BUILDING SEWER(locate on site plan): N/A 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 onsite plan): X Depth below grade: 2" Material of construction: X 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: 1,000 GALLON PRE CAST Sludge depth: 4" Distance from top of sludge to the bottom of outlet tee or baffle: 26" Scum thickness: P, Distance from top of scum to top of outlet tee or baffle: 12" Distance from bottom of scum to bottom of outlet tee or baffle: 17" How were dimensions determined: ASBUILT AND TAPE Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): MAIN TANK AT WORKING LEVEL.TANK AND COVERS 2"BELOW GRADE.OUTLET BAFFLE,NO SIGN OVERLOADING. GREASE TRAP(located on site plan) N/A 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.): Title 5 Inspection Form 6/15/2000 7 Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 164 MEGAN ROAD HYANNIS,MA 02601 Owner: HERTZ,BRUCE Date of Inspection: MARCH 1,2001 TIGHT or HOLDING TANK: N/A (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/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: N/A (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.,): PUMP CHAMBER: N/A (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 Title 5 Inspection Form 6/15/2000 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: 164 MEGAN ROAD HYANNIS,MA 02601 Owner: HERTZ,BRUCE Date of Inspection: MARCH 1 2001 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits,number: 2 AT 1,000 GALLONS EACH leaching chambers,number: 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.) OLD PIT AT OUTLET LEVEL.PIT AND COVER 4"BELOW GRADE.OLD PIT HAS OUTLET TEE TO NEW PIT. NEW PIT HAS 6"WATER,NO HIGHER STAIN LINE. WALL CLEAN PIT AND COVER 18"BELOW GRADE. CESSPOOLS: N/A (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: N/A (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.) I Title 5 Inspection Form 6/15/2000 9 Page 9 of 1 I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 164 MEGAN ROAD HYANNIS MA 02601 Owner: HERTZ,BRUCE Date of Inspection: MARCH I,2001 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two pennanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building: W .-D ��. �� „ o F� J Title 5 Inspection Fonn 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 164 MEGAN ROAD HYANNIS,MA 02601 Owner: HERTZ,BRUCE Date of Inspection: MARCH 12001 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater 25.3 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: Observation site(abutting property/observation hole within 150 feet of SAS) X Checked with local Board of Health-explain: IGS Checked with local excavators,installers-(attach documentation X Accessed USGS database-explain: You must describe how you established the high ground water elevation: USGS WELL DATA WELL AIW 230 25.3 BARNSTABLE HEALTH IGS AND ELEVATION 25' Title 5 Inspection Form 6/15/2000 11 r TOWN OF BARNSTABLE LOCATION @ � �� {�-� SEWAGE # � VILLAGE S i-e�ti S ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. G'� iA SEPTIC TANK CAPACITY LEACHING FACILITY:(type) . �- a4S`� Pt 1 (size) NO. OF BEDROOMS PRIVATE WELL BUILDER OR OWNER c- DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED:VARIANCE GRANTED:GRANTED: Yes No ,� � �� t. �1. � L.` � ���` Z (6 _� �� -o �'. 4 - +t';J Fims.... .d........... THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH TOWN OF BARNSTABLE , pphration for Disposal Works Tumitrurtiun Prruat Application is hereby made for a Permit to Construct ( ) or Repair (�n Individual Sewage Disposal System at: ........ ....... .• ...... •-•_._.._...••- Location-Address or Lot No. vko s_i------------------------------- .............. "" - -............... Owner Addre a ••-•....._�lP���.5..1Q.. SL"' �1. ................................ -----•--•-•-= f. ...... Installer Address M d Type of Building Size Lot............................Sq. feet U Dwelling—No. of Bedrooms...........................................Expansion Attic ( ) Garbage Grinder ( ) Other--Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( ) dOther fixtures .----•------•------------------•------•---------------•--------------------------------- ....... W Design Flow......... ..........................gallons per person per day. Total daily flow............................................gallons. 1:4Septic Tank—Liquid capacity-1 ?gallons Length................ Width................ Diameter................ Depth................ W Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. � (Seepage Pit No....._. ` t ............. Diameter Depth below mlet._._.�__.:..._._. Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by.......................................................................... Date........................................ Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................ 44 Test Pit No. 2................minutes per inch Depth of.Test Pit.................... Depth to ground water........................ Al ......................................................... •.......... •-------------------------------- ------------•••-•------------•••-••••-•--------•--- 0 Description of Soil........................................................................................................................................................................ x W ---••-•---•------ ---------------------•- ------------------------•• •----------••••••----••-••------•-------•--•-----------------• -------------------------------- v ................. ------ ....... fin--- ....SUN— G S S v Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has bqen issued by the b and of ealth. �� Slgne �` '--- -- --------------------------'--... ..— --...---Date--...-_--........ - ApplicationApproved By .............................................. ............................... ... ........................................... .......... Dare Application Disapproved for the following reasons:o ------ ------------ ----- ---------------------------- ---....................................---------- ............. ...... .. ----- -- . ------- .............................. --....-------- .e................. +� Dare PermitNo. �c ..-...t� �.................. .... Issued .----.....------------.........-- .....-------- ---- Date a; Fizz_..... �? THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE Appliratiou for Disposal Works Tonstrur#inn 1rruti# Application is hereby made for a Permit to Construct ( ) or Repair ( an Individual Sewage Disposal System at .....-• -------......-- --- ------------ ........................... .................. - -- ---------------------------- v L`c !on-f ddress 5 Vit-Q`- or Lot No. W C�lA P F L tAH(� �1 L {J= O • boy nea g(n Tg. o 1 - ...... ... ....._ - ----- Installer Address Type of Building 2J Size Lot---------------------------Sq. feet ,., Dwelling—No. of Bedrooms--------------------------------------------Expansion Attic ( ) Garbage Grinder ( ) a`4 Other—T e of Building No. of ersons--------•------------------- Showers YP g -------------------••---•--- P ( ) — Cafeteria ( ) � Other fixtures ":,a ----------------------------------------- WDesign Flow...............................:..�. _,gallons per person per day. Total daily flow----.--.._.-----...-------------------------gallons. WSeptic Tank—Liquid capacity......_...gallons Length................ Width................ Diameter................Depth................ xDisposal Trench—. o..................... Width_:__.4_ ......... Total Length--__---- ....t-- _- Total leaching area--------------------sq. ft. Seepage Pit No._•------_.-_______ Diameter......k.v__..... Depth below inlet------b......... Total leaching area----_-----------sq. ft. Z Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by-------------------------------------------------------------------------- Date_.------------------------------------- a Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water--_•_-__-__-_-_----_-__. _ 44 Test Pit No. 2....%..........minutes per inch Depth of.Test Pit-------------------- Depth to ground water------..-_----------___- s9 ----------------------------------------------------------------------------------------------------•---------••--------••-------------••--•--____.-------- ODescription of Soil..........................................................................)• --------------------------------------------------------------------------•------------- W , U ------------------------ •---- •--------------------------------------------------- •-------------------------------------------------- ------------------------------------------------------------- ------ W •---•----------------------------------------------------------------------------------------------------------- `---------- - ......=•--------------------- x _I_i�5\ iG1t1 I �1W �A'\\Uvv U Nature o Re airs,or Alterations—Answer when applicable_______________________________________________________________________________________________ Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance-has issued by-the�board of-health. Signed ............ -( - .-/"... -------- ApplicationApproved By ................................................. ---------------------------------------------------------------------------------------------- -------rive----------------- s. Application Disapproved for the following reasons- ---------------------------------------------- -------------- :.-,.............................................................------ r ---------- -------------------------------------------------------------- ----- ------------------------- - ----- D----'-------------------------------=-=- ate PermitNo. a.." 3- ----------------------- Issued ------------------------------------------------------------------ Date l THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE �EX#i�tC�t#P II� Compliance L.� THIS IS TO CE AThF, That thVjndi=vjdua1-,Sewa a Disposal System constructed or Repaired � b ---------------------------------- ---------------------------------- at ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of The State nvironmental Code as described in the application for Disposal Works Construction Permit No. ..........�? _ '1' .._. dated ................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE------------------------------------ r 3 '......-------------------------------- Inspector.::------------ i' ------------------------- THE COMMONWEALTH OF MASS'ACHUSETTS BOARD OF HEALTH 7-2 TOWN OF BARNSTABLE No......................... F....... �C� -- Dis pos tl w �urkp T,, ns tun frrutit Permissionis hereby granted ---------------------------------•----....-------•---------------.....------..._.....------.........----.............•...--- to Construct ( ) or Repro( ) an'�Individual Sewa � Disposal Systemh �,�,1 S atNo. -------------------------------=-•----------•--•-----.....•-•--•-----------•-••-...-------•-•-----------•-----•--••...•--- "i# Street /�-�3 f as shown on the application for Disposal Works Construction Permit No........:............ Dated.......................................... � ' ' .........................'.._ Board -- Health -------------------------------------- - — DATE.............. 'fir a % - a` FORM 36508 HOBBS R WARREN.INC..PUBLISHERS "�`' " TOWN OF BARNSTABLE if)CATION /4 y M £ 6 *-� SEWAGE # VILLAGE !� ASSESSOR'S MAP & LOT °9 9 I AME & PHONE NO. A & B CANCO 775-6264 .SEPTIC TANK CAPACITY - � �e LEACHING FACILITY:(type) (size) NO.OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER i Al £C rl DATE DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No 1 Oe 4