HomeMy WebLinkAbout0108 MITCHELL'S WAY - Health 108 Mitchell's Way, Hyannis
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Commonwealth of Massachusetts
W Title 5 Official Inspection Form
� �v
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .
M 108 Mitchells Way °
Property Address
Raf LLC
Owner Owner's Name :
information is i✓
required for every Hyannis � v WA 02601 06/26/18
page. City/Town State Zip,Code Date of Inspection �r1
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.
filling
out forms
A. General Information-, -s/ 3 I
filling out forms -
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Richard T. Johnson
use the return ke
y.Y Name of Inspector
D &J Environmental Services
„b Company Name
P.O.Box 1439
Company Address
Plymouth MA 02362
City/Town State Zip Code
508-735-8740 S113545
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
b Title 5 (310 CMR 15.000).The system:.-
,
Passes ❑ Conditionally Passes ❑. Fails
❑ Needs Further Evaluation by the Local Approving Authority
06/26/18
or's ignatur Date-
The system inspector shall submit a copy of.this inspection.report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes coniiitionsat the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1.of 17
4
Commonwealth of Massachusetts
Title 5 Official Inspection: Form k
Subsurface Sewage Disposal System Form - Not-for Voluntary Assessments
M 108 Mitchells Way "x
Property Address
Raf LLC'.
Owner Owner's Name W
information,is
required for every Hyannis .MA ; 02601. 06/26/18 3
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: 47
® 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:
All system components are within 6" of grade.
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
ldetermined," please explain.
The se tic tank is metal and over 20' ears old* or the septic tank whether metal or not is structurally
p Y p ( ) Y
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3/13` z " Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title..5 Official Inspection Form % R . • y
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments,
M 108,Mitchells Way
* Property Address
Raf LLC R
owner Owner's:Name, 4 a
information is a,
required for every Hyannis '` +. ;., rIVIA," 02601 06/26/18
page. City/Town State, z:.:.Zip Code Date of Inspection '
r B..Certification' (cont;)- ., .,..
❑ Pump Chamber pumps/alarms�not operational:.System will pass with Board of Heaith appr'o4''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 s
to broken or obstructed pipe(s)or due to a broken; settled or uneven'distribution box. System 'Will'. , p
pass inspection if(with approval,of Board of Health): F
} .. - ... .•F .♦,.:R .' .. 4 - ter= s .
. ' broken pipe(s)Aare replaced ❑ Y . ❑.N ❑ ND (Explain belOW):. -
^_ R
❑ obstruction isremoved . ❑ Y ❑ N' ❑ ND (Explain below): g
distribution,box is leveled or replaced ❑ Y; ❑ N ❑ .ND (Explain below):
FY
❑ The system:required pumping more than 4 times a year due to broken or obstructed pipe(s): The
t system will pass inspection`if(with approval of the Board of Health): -
r.
+r
' 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 CMFk"''
>� 15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and"tFie environment:
-❑ , Cesspool or privy is within 50 feet of,a surface water
Cesspool or privy is:'within 50 feet of a'bordering vegetated wetland or a salt marsh
t5ins 3/13 ti Title 5 Official lnspecton Form:Subsurface Sewage Disposal System Page 3 of 17
41
w,
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Commonwealth of Massachusetts .~ '
W Title 5 Official inspection.form`
^' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
° M 108 Mitchells Way l
Property Address R
Raf LLC
Owner Owner's Name
information is H anni's . MA 02601 06/26/18.
required for every y -
page. City/Town State Zip Code Date of Inspection
B. Certification (cunt.)
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:
El 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
/V t supply well.
❑ The system has a septic tank and,SAS and the SAS is less than 100 feet but 50 feet or
more from private water supply}well**.
y Method used to determine distance`
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal A '
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.
El ® Backup-of sewage into facility or system component due to overloaded o
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
1-1 ® Liquid depth in cesspool is less than 6 below invert or available volume is less
than %day flow . .
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
W Title 5 Official- Inspection Form ,
Subsurface Sewage Disposal System Form -Not'for Voluntary Assessments r'
�M 108 Mitchells Way '
Property Address
Ralf LLC .
Owner Owner's Name
information is Hyannis -MA 02601 06/26/18
required for every Y _
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:
❑ E Any portion of the SAS, cesspool or privy is below high ground water elevation.
El ® 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 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.p' rivy 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
El. ® 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
1� ❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200•feef of a tributary to a surface'drinking water supply
E] the system is located,in'a nitrogen sensitive area(Interim Wellhead Protection
El Area-IWPA) or a'mapped Zone li 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 undei Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 .
Y
Commonwealth of Massachusetts
Title-5 Official Inspection, orm'a
Subsurface Sewage'Disposal System Form -Not-for Voluntary Assessments ✓
M 108 Mitchells Way r
Property Address
Raf'LLC
Owner Owner's Name 4
information is
required for every Hyannis MA 02601 Y 06/26/18
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 anytof 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?
spection?
• Were"as built plans-of the system obtained and examined?,(If they were not
® ❑ available note as N/A)F
® ❑ ` Was the facility or-dwelling inspected for signs of sewage back up?.
❑ El Was the site inspected for signs of breakout?
❑ ❑ Were all'system„components,excluding the SAS, located on site?
El VVerefthe ssptic tank manholes uncovered, opened, and the interior of.the tank
inspectedfor the condition of the baffles for tees, material of-construction,
di-mensions, depth of liquid,,depth of sludge and depth of scum?
Was the facility owneri(and occupants if different from owner) provided with
® 0 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 failuee criteria,related to Part C is at issue
❑ approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
F
Res idential..Flow'Conditions:
Number of bedrooms(design): 3 ( )Number of bedrooms actual :
r
( 9
330 GPD
t, DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms):
t5ins-3/13. - Title 5 Official Inspection-Form`.Subsurface Sewage Disposal System-,Page,6 of'17
Commonwealth of Massachusetts
Tithe 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not,for Voluntary Assessments
M 108 Mitchells Way
Property Address
Raf LLC
Owner Owner's Name
information is Hyannis MA 02601 . 06/26/18
required for every y
page Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ®` No
Is laundry on,a separate sewage system? (Include laundry system inspection ❑ 'Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonal use? - ❑ `Yes,-® No
Water meter readings,,if available (last 2 years usage (gpd)):
Detail:
2016: 30.9 GPD, 2017: 41.9 GPD
Sump-pump? ❑ Yes ® No
Last date of occupancy-- Presently
Date
Commercial/Industrial Flow Conditions:
Type'of Establishment:
Design.flow(based on 310 CMR 15.203): r. Gallons per day(gpd)
Basis of design flow,(seats/persons/sq.ft. etc.):
Grease trap.present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes .❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts?
r -
W Title15 Official Inspection Form .
Subsurface Sewage Disposal System FormF- Not for Voluntary Assessments
°M 108 Mitchells Way
Property'Address
Raf LLC
Owner Owner's Name '
information is required for every Hyannis MA 02601 06/26/18
page. City/Town State Zip Code Date of Inspection
D. SystemInformation (cont.)`
Last date of occupancy/use: Date ,
.Other(describe below): i
General Information
Pumping Records:
Owner • .
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
Septic tank;distribution box, soil absorption system
❑ Single cesspool,
❑. Overflow cesspool
❑ Privy
El 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•3113 Title 5,Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
I ,
Commonwealth of Massachusetts*"
w Title 5k Official 1h'06dti6,n. Forme -
Subsurface Sewage Disposal System'Form -'Not for Voluntary Assessments
108'Mitcheils Way,.t
Property Address x_ ,
Raf LLC
Owner Owner's Name r ;
information is r
required for every Hyannis MA 02601 06/26/18
page. ' ' City/Town —State , '1 Zip Code Date of Inspection
D. System information. (cont.)
j Approximate age of all components, date installed'(if known) and source of information:,,,
1998 4 �
Were sewage odors detected when arriving at the site? ❑ .Yes ®.'No
Building Sewer(locate on,site plan):
rDepth below grade: �? 3.5 f
feet
Material"of construction: +�
4 ti w
x
^;❑-cast iron 40,PVC . ❑+other(explain):
F � z . 6 a.
Distance from-private water supply well or suction line`._
». ffeet'
' Comments (oncondition of joints, venting, evidence of leakage, etc.) -
joints structurally sound, no signs of leakage .
.
Septic.Tank(locate on site plan):
Depth below grade: 3 '
' feet
Material of construction:
.® concrete ❑ metal' ❑ fiberglass ❑ polyethylene ❑ other(explain)
Septic Tank Cover on risers to within 6" of'grade.
If tank is metal, list age: F• '.
years
r Is age,confirmed by a'Certificate of Compliance? (attach`a copy'of certificate) ❑ Yes ❑ No
x 1500 Gal,,
Dimensions:
• Sludge depth: 5' —
t5ins•3/13 , Title 5 Official Inspection Form:Subsurface Sewage Disposal System a Page 9 of 17
•
Commonwealth of Massachusetts
„ .
W Title 5 ®ffici6l44lnspection "Form
Subsurface.Sewage Disposal.System Form - Noffor Voluntary`Assessments
108 Mitchells Way: 5.
Property Address
Raf LLC r
Owner t Owner's Name
information is "
' Hyannis MA 02601 06/26/18 fi
required for every --
page. City/Town State , -'Zip Code Date of Inspection
D System information (cont.)
d
Septic Tank(cont.)
Distance from top offisludge to bottom of outlet,tee or baffle
3
Scum thickness
Distance from top-of scum to top.of outlet tee or-baffle „. . 5 "
3„ w
Distance from,bottom of scum to bottom of outlet tee or baffle
How were dimensions.determined? Field measurement/Mfg. Spec
w A Comments (on pumping recommendations, inlet and'outlet tee or baffle condition, structural integrity,
liquid.levels as related to outlet invert,'evidence,of leakage, etc.):
Sanitary tees i,n good working condition, tank structurally sound, no evidence of leakage.- All
components rated at H10 and are.not proximate to load bearing conditions. Recommend--tank.be
pumped to extend life of components. .. k s "
..,. "a
Or
Grease Trap (locate on site plan): Y a
Depth below✓grade: f_ }
feet
Material of construction: yt„,
❑ 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
F
t5ins 3/13 Title 5 Official'.Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
f
Commonwealth of Massachusetts,A
W Title &-Official nspection Form
Subsurface Sewage Disposal°System Form - Not for Voluntary Assessments
. 108 Mitchells'Way
Property Address
- Raf LLC _
Owner Owner's Name
information is Hyannis MA 02601' 06/26/18
required for every. y
page. City/Town, - State . Zip Code -.Date of Inspection 7
Do 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.):
a
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
concrete ❑ metal :`, ❑ fiberglass ❑,polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
- gallons per day e
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
A.
l5ins•3/,13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
tN
Commonwealth of Massachusetts
Title 5 Official llnspection Form
Subsurface Sewage Disposal System form- Not for Voluntary Assessments
M 108 Mitchells Way
Property,Address
Raf LLC
Owner Owner's Name
information is Hyannis MA 02601 06/26/18
required for every y
page. City/Town State Zip Code Date of Inspection
D. System Information:{cont.)
Distribution Box (if present must be opened) (locate on,site plan):
0„
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,):
Box level, no evidence of solids carryover, no evidence'of leakage into or out of box.
k
Pump Chamber(locate on site plan).-
Pumps in working order: ❑ Yes ❑ No*
• ' Alarms in working order: ❑ Yes ❑ No*
Comments note condition of um chamber, condition of pumps and appurtenances, etc.):
( pump � P p Pp )
* If pumps or.alarms are not in working order, system is a conditional pass.
Soil Absorption.System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 12 of 17.
Commonwealth of Massachusetts,
Title 5 Official Insp�ecttion Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
' M 108 Mitchells Way
Property Address
Raf LLC
Owner Owner's Name
information is required for every Hyannis MA 02601 06/26/18
page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits, ; Number:
® leaching chambers number:
❑ leaching galleries number:'
❑ leaching trenches number, length:
❑ leaching fields 't, number, dimensions:
❑ overflow cesspool ' number:
t
❑ innovative/alternative system {
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
' .Vegetation, etc.):
No evidence of Hydraulic failure, no damp,soil, normal vegetation.
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 A F
Depth of scum layer
a
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form -
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
108 Mitchells Way
Property Address,
Raf LLC
Owner Owner's Name
information is Hyannis _MA" _ 02601 06/26/18
required for every H Y '
page. City/Town State Zip Code Date of Inspection
D. System Information-(c'ont )
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 ;
l Depth of solids R.
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
r
t5ins•3113 t Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
I
Com, monwealth of Massachusetts_
Title 5 Official inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
108 Mitchells Way
Property Address ,
Raf LLC
Owner Owner's Name
information is
required for every Hyannis MA 02601 06/26/18
page. Citylrown State Zip Code Date of Inspection
m System IlnformatI6n (cdnt.')
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,
F
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
l
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
108 Mitchells Way ;
5 ,
Property Address
Raf LLC
Owner.' Owner's Name
information is , ,* `
required for every Hyannis MA 02601 06/26/18
page, City/Town .State Zip Code Date of Inspection
D. System Information (co'nt.)
Site Exam:
® Check Slope
® Surface water
® 'Check cellar s
❑ Shallow wells
Estimated depth to high ground water: NGWE at 120" (10 Ft)
feet
Please indicate all methods used to determine the high groundwater elevation:
❑ Obtained from system design plans on record
1998
If checked, date of Date design plan reviewed: P
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:
T
You must describe how you established the high ground water elevation:
Obtained from site observation, visual elevation, As Built&soil log data on file with BOH dated
3/25/98.
Before,filing this Inspection'Report, please see.Report Completeness Checklist on,next page..
t5ins•3/13 Title-5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16of 17
c
r
Commonwealth of Massachusetts J
Title 5 Official Inspection Form
Subsurface Sewage Disposal-System Form'-Not-for Voluntary.Assessments
M 108 Mitchells Way +
Property Address
Raf LLC
Owner Owner's Name
information is Hyannis MA 02601 06/26/18
required for every y -
page. Cityrfown State Zip Code Date of Inspection .
E. Report Completeness Checklist
♦
® Inspection Summary: A, B, C, D;or E checked
® Inspection Summary D (System F5il6re 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
d.
t5ins•3113 'Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 17 of 17
�\
YOU WISH TO OPEN A BUSINESS?
For Your Information: Business certificates (cost$30.00 for 4 years). A business certificate ONLY REGISTERS YOUR NAME in town (which you
must do by M.G.L. - it does not give you permission to operate.) Business Certificates are available at the Town Clerk's Office, 1s' FL., 367 Main
Street, Hyannis, MA 02601 (Town Hall)
DATE: O'. I Z Z 'O
Fill in please:
APPLICANT'S YOUR NAME: t1 .. '® A \j f�G a
q BUSINESS YOUR HOME ADDRESS: /®'$ d`h(`i' C
------------
�.rry Qk TELEPHONE # Home Telephone Number CSz,
NAME OF NEW BUSINESS A-& TYPE OF BUSINESS N k1
IS THIS A HOME OCCUPATION? 3C YES NO:
Have you been given approval from the building division? YES
ADDRESS OF BUSINESS d0 1. >a,f,1,-S A MAP/PARCEL NUMBER U U
When starting a new business there are several things you must do in order to be in compliance with the rules and regulations of the Town of Barnstable.
This form is intended to assist you in obtaining the information you may need. You MUST .GO TO 200 Main St. (corner of Yarmouth Rd. & Main
Street) to make sure you have the appropriate permits and licenses required to legally operate your business in this town.
1. BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature".
COMMENTS:
2. BOARD OF HEALTH
This individual h be n inf rrned of the per it,,,Oequirements that pertain to this type of business.
honze�j Signature`* '
COMMENTS: J, n7
3. CONSUMER AFFAIRS IC NSING AUTte
RITY)
This individual has inform d of ' si equirements t pertain to this type of.business.
Au horized Signature**
COMMENTS:
Date: 03/ /
TOWN OF BARNSTABLE
TOXIC AND HAZARDOUS MATERIALS ON-SITE INVENTORY
NAME OF BUSINESS: AC�O I
BUSINESS LOCATION: 1 171� M�TC�N�,�,1 S �.,�JV �IJ INVENTORY
MAILING ADDRESS: `� ►11v� 1-c-— TOTAL AMOUNT:
TELEPHONE NUMBER: 504 ��Lr-? O ` Q31-6
CONTACT PERSON: 502) j6-0 4T61
EMERGENCY CONTACT TELEPHONE NUMBER: rS2kL6- o - 6 f MSDS ON SITE?
TYPE OF BUSINESS: Llly-7 IV 6
INFORMATION/RECOMMENDATIONS: Fire District:
Waste Transportation: Last shipment of hazardous.waste:
Name of Hauler• Destination:
Waste Product: Licensed? Yes No
NOTE: Under the provisions of Ch. 111, Section 31, of the General Laws of MA, hazardous materials use,
storage and disposal of 111 gallons or more a month requires a license from the Public Health Division.
LIST OF TOXIC AND HAZARDOUS MATERIALS
The Board of Health and the Public Health Division have determined that the following products exhibit toxic
or hazardous characteristics and must be registered regardless of volume.
Observed/Maximum Observed/Maximum
Antifreeze (for gasoline or coolant systems) _ Misc. Corrosive
_ NEW USED Cesspool cleaners
Automatic transmission fluid Disinfectants
Engine and radiator flushes Road Salts (Halite)
Hydraulic fluid (including brake fluid) Refrigerants
Motor Oils Pesticides
NEW USED (insecticides, herbicides, rodenticides)
Gasoline, Jet fuel, Aviation gas Photochemicals (Fixers)
Diesel Fuel, kerosene, #2 heating oil NEW USED
Misc. petroleum products: grease, Photochemicals (Developer)
lubricants, gear oil NEW USED
Degreasers for engines and metal Printing ink
Degreasers for driveways &garages Wood preservatives (creosote)
Caulk/Grout Swimming pool chlorine
Battery acid (electrolyte)/Batteries Lye or caustic soda
Rustproofers Misc. Combustible
Car wash detergents Leather dyes
Car waxes and polishes Fertilizers
Asphalt & roofing tar PCB's
Paints, rnishes, stains, dyes Other chlorinated hydrocarbons,
Lacquer thinners (inc. carbon tetrachloride)
NEW USED Any other products with "poison" labels
Paint&varnish removers, deglossers (including chloroform, formaldehyde,
Misc. Flammables hydrochloric acid, other acids)
Floor & furniture strippers Other products not listed which you feel
Metal polishes may be toxic or hazardous (please list):
Laundry soil &.stain removers
(including bleach)
Spot removers &cleaning fluids
(dry cleaners)
Other cleaning solvents
Bug and tar removers
Windshield wash
WHITE COPY-HEALTH DEPARTMENT/CANARY COPY-BUSINESS
ColVdvioNwEAL'I'H
OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMEN TAL AFFAIRS
DEPARTMENT OF ENM0NMENTAL PROTECTION
ONE WL,;M STREET.BOSTON MA 02108 (617) 292-5500
TRUDY COXE
DAVID B.STRUHS
C
ARGE0 PAUL CELLUCCI POWA
Goeernam DACE SEWAGE pISPOSAL SYS1B//tSPEf:TIDN
TART A y
CEIRTIFICA
14Y � + S /lQ�•FR-
Addr•ai /Dp m �-r'g�65 40 4Y ��o.mr. /�,� a1�
15_0001
,5 310`� �a�.3c rS
osoe of °". �Madm.*S `�
Nan.of I Do approved
sys"M �..R toSaedaa 15.340 a!1M.5 A10 CM, .; - Re Js ��'f` tom?A ss o
No
Compan
w, .: :..s►,t Q a t
roe, -I"STATEMEIR al system at*,a address and that the information reparmd blow h true. accurate
1 esrdrll that 1 have personaW inspected the sows"
a inspection
coon w as pwfwnwd based on my gaining and egwwnce in th proper function and
and complata as of the time of inspection TM inapecfien
maintenance of on-site sewage disposal systems- The system:
r/Passes
Candhiandy Basses
Needs Further EvaY+atioe By to Local Approving Authority
Fab
Inspec"es Signaeme'
a of this inspection report to the APpra�Authoritll IBowd of Hasith or OEPlwiehin thirty 1301 daysni+
The system kupeetm shd wbmR copy has a deign Derr of/0.000 gpd or greater.tea and the systarrn
this i apecdon. If the sYstam is a>nlnarad sYstemt protection.tion. TM should be sent to t1a shell submit the"Wert 4�the appropriate regional once of the DepaAmant of EmrirownI
system
owner and copies sent to to buyer.if apoicable.and 11N app.ovnrq audwritY-
,,� CoOI Poiv, •�l
NOTES AND COMMENTS S Y s T
c0A1
T rQ/tl AN7). � o ?c2riT� Nam. i4S �rS/Gwc'.�
- 44),
4 H' "a"VoFB g 00
revised 9/2/98
�1a111 �
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM
PART A
C8(T(FTCATION loondn"
Prmpaty Address:
Owner.
Ow of Inspection.
99SPECTWU SUMMARY: Check(9 B, C, or a
A. SYSTBt PASSER:
1 have not found any information which Indicates that any of to false conditions described in 310 CUR 1 S.303 exist. Any failure
enteric not evaluated are indicated below.
.ITS:
B. SYSTSA CONDITIONALLY PASSES:
NT One or awe aystarn camponrnts as described in the'Conditlonel Pass'section need to be replaced or spied. The*"%am.upon
completion of the replacement or repair.as approved by the Board of Health.will pass.
Indicate yes.no.or not determined(Y. N.or NO). Deserbe basis of depnnination In at instances. B'not detanNnad',explain why not.
The septic tank is metal.unless the Owner or eperaDo has provided the system inspector with a copy of a Cadfieate of
Canpliance lanwhed)indicating that the tarn was instated wit in twenty(201 years prior to the data of the inspection: or
the septic tank.whether or not meal.is cradn4 sbucsnally wound.shows substantial itfi)tradon or ex6tratlon,or tank
fairs is brA*att. The system will pass Inspection B the existig septic tank is replaced with a comply(np saptle tank as
approved by tlna Board of Health.
Sewage backup or breakout or high static watr level observed in the distribution box is due to broken or obsowted pipelsl
or due to a broken.settled or uneves dsbftdion boar. The systo will pass kwpeetion If(whh approval of the Board of
Haahh).
broken pips(s)are replaced
obstruction Is removed
istsibudon box is Isvated or replaced
The rta m required pu mpknil more then few 11mes a yew dus in broken or obstructed pips(s). The systern will pass
inspection N(with approval of the Bard of Heeldd:
broken pipolel are replaced
abstiruetlon is r-arovwd
revised 9/2/98 PW2or11
' s
' SUBSURFACE SEWAGE OISPOSAL SYSTEPA NSPECTIOM FORM
PART A
CER IFICAT10M kontinaadl
Ptapw"Ad*esa:
owner:
Once at kopU dow:
C. Fjff tot EVAWATm IsREaummBY TtE BOARD OF HALM
Coaddem exist whsd+ts4tore fa rlhw evsbae m by do Board of HaaMh in=der to data wmw d the system is%Nne to proms dw
ptthfie haaldt.ttstaty toad the etrritotattnrt• +.
11 SYwm WILL PASS 1M•ESB BOARD OF l*ALM DETUMO El N ACCORDANCE WITH 31O f EIR IS- fl18+17HAT THE SYSTEM
6 NOT FIJNCT10NN6 N A MANNER WH KH WU PROTECT THE PUBLIC HEALTH AI IO SAFETY AND 1Mf BVNNOWABITz
Cesspool or privy b wi1M SO be of satface wow ��a a salt rtwsh.
_ Casopw or privll is witm SO feet of a bwdo Mgeaad
SYSTEM IS
21 SYSTEd Wlll FAIL W1LE55 THE BOARD OF Mal"
WM PUBLlG WAT81 SUPPLIER.IF DETERMpm
THAT THE S
pjNC wMNG N A NANN6t THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE E/vIRONMEI T:
The syswrn has a septic tank awl sail abaarpdora xVxwn($AS)and the SAS is within 100 foot of a surface water supply or
tributary m a sud=O water supply.
_ TM syatetn has a sepdo vdt and soft absorption aVstwn and the SAS Is widlin a Zone 1 of a publk water supply WON-
The
The system has a sapde bat and a absorption t Vst�md the SAS is w1
and 5o fact at private water supply wall.
. — Thai systsrn lass a aepdes tart and sog b ahsorpdett stwta end tlaa SAS is lea don 100 fast but 80 tact or indicaw that d+
0h�wow supply wall.adess•web castor araalyais far coiforanownla rm-bammis and�mw nitrate tritia- a4�da4"rb to or less
wee is free fraw pantatien iron dear faclTaY arrd dw presence of t lq*rmknuftn nut 1.
than S ppnL Medved aced to dots eirw distance
31 OTHER
revised 9/2/98 ftV3of11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERT6iCAT10N Ronda v4
Proparty Address:
Owner•.
Data of btapeeSorK
0_ 3YSTM FATS:
You mast indicate either'Yes'or'No' to each of 1M follawirtg:
a//� I have determined that one or more of the following fog-, condition east as dasaI in 310 CM in 303. The basis for des
daterminadan Is idsadfiOd below. The Dowd Of Health should be oarteeted to detanniw chat wN be necessary%a cevact the falure.
Yes No
Baduup of sewage into facility a system component due to an overloaded or dogged SAS of cesspool.
Discharge or pending of afluent to the surface of the grand at starter weews due to an Overloaded of
cesspool. dogged SAS a
Static liquid level in the distribution box above oudet invert due to an overloaded or dogged SAS or cesspool.
Uquid depth in cesspool is less than 6'below btvart or ova&&@ volume is less then 112 day flow.
Required pumping more than 4 times in the last year NOT due to d
Number of times o °r obstructed pipMal.
Pumped
Any portion at the Saul Absorption System.cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet Of a surface water supply at vibutery to a surface water supply.
Any portion of a cesspool or privy is withk a Zone I of a pubic well.
Any portion of a cesspool or privy is witiii►50 feet of a privaae water supply wag.
Any Portion of a cesspool or pd"is tees-than 100 feet but greater then 50 fast from a private water supply well with no
acceptable water quaft analysis it ow well has baen analyzed to be aowpfabte.attach espy of was water analysis far
eolifam bacteria. o olaeAe argaruie compounds.ammom Nnegen and nitrate ritr ogert.
E. LARGE SYSTEM FAILS:
You must indicate either'Yes' or'No' to aach of the following:
The following criteria apply to loge systy. in sddtion to the criteria above:
The system serves a faeaity with a design tow of 10.000 gpd or greeter ft ar0e SysImM and the systern is a significant threat to public
health and safety and the environment because One or mere of the following wndtions exist:
Yes No
the system is within 400 foe of a surface drinift water supply
the system is within 200 feet at a tributary to a surface drinldrug water supply
the system is tocatad in a nitrogen sensitive area(Intariet Wellhead Protection Ana=IWPA)or a mapped Zone N of a pubic
water supply well
The OvnW or operator of any such system shay upgrade the system in accordance with 310 CUR 15.304(2). Please Consult the local regional
office of this:Department for further 6tfannation.
revised 9/2/98 Page 4of11
SueSURFACE SEWAGE DISPO SYSTI7N NSPECT101r FORM
SAL
PART 8
CHECKLIST
Properttl Adam
Owner:
Daft of bupocd0'C
-yes-a'No' as to each of the qdlowbW
Check if tiw fdbwing have boon done:You must"cats eidter
Yes so was Prod by the owner.oeCtrptPr%or Board of Health.
for at)east t die system weeks end d system has bmm rsemi�/rtasrrtd saw
�
_ None of the System ^potumm how be of en wpm on not been introduced into dw st►stm lacently or as PWt of WO
rates during that period. Largo vakarws
InspectolL
As built plans have been aborirwd and Karrtrted. Note if they we not available with MIA.
/ The fill or dwelling was inspectedfor signs of sewage baekirp.
The system does not receive non.sanitary or indust"waste flow.
The sift was impacted for signs of breakout.
_ •O=W&g the Sol AbsorP oon Syatern.have been heated an the ske-
Aar system eornponents
_ The septic tank rrwnhales were -opened.and the interior of dw septic tank was irarPactod
for eon6tion of baffles
or tees.material of consaucdon• •depth of Squid.depth of sludge.depth of scum.
The size and location of tho Sol Absorption System on the site has been detrained based am
Existinginforntedon.Far MCMPW Plan at O.O.M
Datermired in the Hold of eny of dw hilum criteria rdead to Part C is at N...ttPprotdrrtatiorr of dfattrnee is tsraCC O!
Pz
116.30;t 3HbH
_ land oea�•it&"Merit from owner)wen Prim Mo
provided with rrna m an don P=PK d of
The fae+litY server
SubSurface.Disposal Systenw.
hie S of 11
revised 9/2/98
SUBSURFACE SEW AGE DISPOSAL SYSTOM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: .
Owner:
Diets of Inspection:
FLOW CONOff10NS
Design low:L//0 p.dJbedqpw
Number of bedroant enl: Number of bedroans(acadl:A
Tod DESIGN flow P D
Nunber of current residents:_&
Gsrbsps grinder(Iles or noh�/6
Laundry(separate systarnl IYa or nol: a., If yes. separate inspection required
Laundry systan Inspected (yes or
Seasonal use Iyaa or nol._y S
Water meter readings.If available past two year's usage(CPO: IA
Sump Pump(yes or nol:_d4o
Last data of oeeupaney: gc�
COMMER
Two of establishment:
N/ Design flow: and 1 Based on 15.2031
,+Basis of design flow
Grease trap present:Ives or no)_
Industrial Waste Holding Tank present:(yes or no)_
Non-sarrary wsate discharged to the Title 5 system:Ives or no)—
Water rmeter readings.if svaieMs•
Last data of occupancy:
OTHER:(Describe)
'.sat date of occupancy.
GENERAL INFORMATION
PUMPM G RECORDS and source of in l6nmaion:
A/1
System Pumped as part of inspection:Ives or nol
If yes.voiums panpsd:- gallons
Reason for puanpinng:
TYPE�F SYSTEM
i/ Septic twWdistrbudon bwdsaul absorption system.
Single cesspool
Overflow eesspoot
Privy
Shared system(yea or nd pf yes.attach Previous inspection retards.if any)
VA Technology ate.Attach copy of up to data operation and maintsnance contract
Tight Tank Copy of DEP Approval
Other p
APPROXIMATE AGE of all components.date installed lif known)and source of intamadon: /9 9S / t-,*-A,1 Q gl
13 A4.?.vSi r#,be-c $ .0, lie .
Sewage odors detected when aniving at tha site:(yes or nol._IVC Al 6
revised 9/2/98 Pfte6ofit
` StMSURFACE'SEWAGE DISPOSAL SYSTEPA a1SPECTWO FORM
PART C
SYSTEM NFORMATKlfI 1
Propw tY Addraw:
Owners
Date of
SULDOG SEYYBI: '
(Loom on sin plan) '
A//rOepth bebMr.Oradd:
MaterW of eonsvuctiow_cast iron_40 PVC odrar(explain)
Distenee*am PrWaft water supply well or section line
Dlemeter � eddsrtoa of feakape.etc.)
nts
Conrne :(cm-dhion of joim.vendrq.
SEP't1C
p ecats on sit plan)
Depth below Wade: mad_fibwglsn ,_polyethylene_othg�esplaiM
Material of eonstruedm ZMwe"
If tank is maW.ist age_ b ape confined by Certificate of Compliance (YesMol
Dimensions- 2e 'L t p to' a( W $'
Skrdge depth:_
Distance from top of tsludye to bottom of outlet tee or baffle
Scum thickness:-
Distance from top of scum to UP of outlet tee or baffle:_
Distance from bottom of scum to bottom of outlet tee or baMe:-
iow 8mensions were determined: �/rS i a L i ivS�ECTtC,�/
Carrunenn: of We and outlet toes or baffles.depth of liquid level in edation to outlet invert.strueturd irtelarih.
(ncornrnerrdatlon far pumping.condition v
evidence of leakew.ete.l Al
CREASE TRAP:
pocate on site plan)
Jlll6uXteterid Depth below
' Win'_tea metal Fbar�ass Pdll _otl+aiesplein)
. pin,ansions: .
Sewn d**nss
Distance from top of scum to gap of cutlet tee Or bnf%-,
=stem*fran bottom of son to bottom of owlet tee or be"*:,_�
Dan of last pumpk :
Commas ts. condition a<mot and outlet tees or baffles.depth of f "level in relation to outlet WN01%strutural c b tcgrfhl-
beeoermendatlan for pumping
evidence of Voltage:etc.)
revised 9/2/98 pate 7etll
SUBSURFACE SEWAGE DISPOSAL SYSTEM NSPECTION FORM
PART C
SYSTEM NFORMATMN lcasenued!
Poparty Address:
Cihrner.
ch"at kupecdon:.
T)GNT OR HDLDBIG TARL Rank must be pumped pior to.or at time at.inspeedon)
0-c Im an site plan)
mph blow grade:
Iwt.rid of eonstruedon:eaww.end_Fib«ghss PdVW ybma mbarlesplml
Design Now: gdlpw/day
Alarm present
Alarm lavd• Akins in working order:Yes No
Date of previous pumping:
Commorta:
(condition of Wet tee.condition at alarm and float switdim eto.)
DISTRIBUMN SOX:
(locate on site plan)
n
Dopth at liquid level above oudet invert: l
Comments:
Isom i1 kivd and distribution is oquei.evidence of soids canyover.evidence of knkage into or mat of box.atca
- %fit < fRt R ,)-r0 A,, I cpd,* AIQ jz LJ r r'A-R-,zV .0
PUMP CHA OM
(locate on sits plan)
PwnM in working order:Iles or Mal
f^ Alamm in working order(Yes or mo)
Cornffwm:
Ieete eondidon of pump chamber.condhion of pumps and sppur%nwms.ate.)
revised 9/2/98 Paaeaof 11
SUBSURFACE SEWAGE DEPOSAL SYSTBA BlSPECTION FORM
PART C
SYS7OA NFMMATM loom
itiopst'y Address'
Owner:
Dane of i specti°n= /
SOIL ASSOMmON `- e net lecason wry be approximated by non4nu"w medadsl
90cow on she pyM.
N not loeaRed.otplain:
Type: ..
Mad**pits.number:
h odwq chambers,numbs r—
becift galleries.rwoodo r- g,
bachWq wenches.number.lonsth:
kaadit fields.n+mba•
owfow o ispool.MnMdw-
Altemative system:
Name of T :
Corrunents: faihae,level of poratin9.damp soli•condition of wgeation.etc.) �,F YD JL�tC1C
(note condition of sod.signs of hydrauie
c P
CESSPOOLS:
.(locate on sks plant .
Number and configuration:
�f top of liquid to inlet imam:
A91h of solids lays:
Depth of scum IaYer
Olmansrons of cesspool:
Mearlale of censtrucdon:
Mnticatton at Voundwats'
inflow(cesspool must be pumped as P�of irerpaetion)
Comments. faiwo.kwW of panting.mmudtion of vagetation. etc.)
(note condition of soli.signs of lrydraeic
pf,1NY: .
Oocw an sks plan)
NI Mat aids of eonstruedon:
Depth of aelida:—
Comments. faA,re.levd of pond".condition of vagOtUdOM @W•)
Inate condition of soli.signs of hydraulic
revised 9/2/98 ftr9ofit
SUBSURFACE.SEWAGE DISPOSAL SYSTEM MMECrMN FORM
PART C
SYSTEM NPORMATION leo d)
y Addrem
Oua.sr.
Osu�d bepaction:
SI[ETCM OF SEWAGE DM 0SAL SYSTUt
kchWe In m at bast two pwauram rslow o bnd mwks or bendrnoft
bxab r wWb within IOW(Loeab when public mom supply eomso kft hom)
a`6 '
r
T-c/4 (-::77 cCS L v A-Y
revised 9/2/98 Par lootu
' SUBSURFACE SEWAGE D15POSAL SYSTEM WSPECTION FORM
PART C
SYSTEM DFORMATM lcandr:radl
PmpsM Address:
Oarnmr-
OaMd
NRCS Report rtaeta
sea TVs_
Typkd depth to ptauttd moor
USGS Data vwbmits visited
Observ+dw Wage checked Caep
GrowWwator depth: ShalloW
SITE EXAM Slope
Satiate water
Gtack Cellar
Shallow Waft If
� !
ip
Esdnuted Depth to Groundwater Feet
Please,b"Scate dI.the madwds used to datemtins High Groundwater B6v8dGn=
J,,�Obminad from Design Plans on record
,,-'Observed Site(Abutting property.observation hole.basement sump ote•1'
Determined from local conditions
J�Chackad vAthrlocal Used of haaltlr
Checked FEMA Maps
Chocked pumping records
Checked local aseevators•irutIllars'
Used USGS Data
Describe how you estabidwd the High Wmm wear 6414don.LU-6-4 be
i3Alzry s3As�€ •��0 ��,
wa we -
revised 9/2/98 Page 11ofit
f
i
Please read this notice
Purpose: The information in this report is based on visual inspection of the
listed property. This does not mean that that every defect was discovered.or
uncovered. This report does not offer nor imply a warranty to any defect to
the operation of this system. The process is to visually inspect, as much as
possible,the components of the septic system and to determine if this system
meets the criteria outlined by this report concerning Title Five regulations.
This information is based from the conditions noted at the time of the
inspection. There is no indication given as to the remaining useful years or if
the engineered design flow is at present use of this dwelling. The use of this
information is with the understanding that the above conditions are integral
to this report whether it is from the buyer or sellers position. A copy of this
report will be kept by me and is a available to all parties concerned
If you require further information, please contact me directly at any time.
Tffom s J, Roucpus
781 - ;Zu; - Y309
=�S?Ec:rc;R
ls.�l..e 01/1S/7�1 sage 16 of 10
COMMONWEALTH OF MMSACHLiSETTS
ECLJTIVE OFFICE OF ENVIRONMENTAL AFF
DEPARTh(ENT OF ENVIRONMENTAL PROTEC71ON
ONE VVL'rTER STREET.BOSTON VA 02108 (617) 292-5500
TRUDY COIIE
Sacr t m
DAVM B.STRUM
Commissional
ARCrEO PAIJL CELLUCCI
Govemw DACE SEWAGE DEPOSAL S11S7EY ��~
IPART A
-
�s- rlilss ell
�=... /O y �''r � ;c K K� sf Oeraa � jr1�ss
PropeRll ` Address of Owner t(
Dow at kopecdow e/ 3100 a��3e�rS
Nave�� ��is Saedon IL340 of M"5(310 CM 16-OOM
1 are a 'pProved
CoTP�N,mo; Ra
Hamm Addmc f_.[�. oyl -
Telepf"w Numbers
is true. acewate
T10N systwR at this address and Intl dw kft"nsrion reported below function and
AT�f r tun
^d the sewage in the
Isom persondll laspaeb based on M11 trairMtg and Pie
end conq&w as of the tiara of Wmecdon- The in peCfn w.pw%nned
msmtenance of an-site se�vre"disposal systsms- The system-
rf Passes `
_ Condtiona/y Passes
N Far*w!:valuation gy the local Approving AulhotitY
�
'- Fell
bmpsaws of
a' of drs iespection report t° App° Audwf*(Board of HsaRh or DEPlwithin thirty 1301 days
The,Syat,aa+Inspector abet whorl copy or has a design flow of 10.000 gpd or Wester.the inspector and the system
cornployf this impacd1101
on. B 1M system h a shared systant of Ertvborrnsntd��om TM origind shadd be seat to the
shall submR the repel to the ap,gWM tonal ofF48 of the DepaAn w"
system owner copies sent to the buyer.if appge>�•and the*WOW* h-
Y S'T6 a1
roar-?a Al
rt�� i.v Pc��� �'tW
lJ
NOTES AND COMMENTS s 7j c S PGw C'b
v
�. 3
00
revised 9/2/98
�1 el Ii
ti
Y
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECTION FORM * '
PART A
C6iflRCAT10N(condommG
Prwpm ty Address:
Owner:
Dow of kupudow
BMSPECTION SUNIUkRY: ChW4 AL C, or 0-
A- SYST9M PASSES:
1 have not found eery information which brdkates that any of the failure conditions described in 310 CUR I S.303 exist. Any failure
criteds not evaluated am indicated below.
CATS•
B. SYSTEM CONOnUMALL.Y PASSES:
A//i� One or awe system compoe ants as described in the'Conditions!Paw"aaction need to be replaced at repoked. The system.upon
cormpl tiorr or the nepl.e.rrr.rrt«repair.sa apprwd by the Board of Health.wMl pass.
Indicate yes.no.or not determined(Y.N.or NO). Descdbs basis of deter instion(a all instances. tf'not daboiined'.espidn why not.
The septic tank is metal.unless the owner or operator has provided the system inspector with a copy of a Certificate at
Compfian ce(attached)indicating that the tank was ionI 1 within twenty(201 years prior to the date of the inspection: or
The septic tank.whether or not metal.is cracked.structurally wound.shows substantial ih ON-don or oxfltrodon. or tarok
fa ure is i rakent. The system writ pass inspection B the septic tank is replaced with a eomplyinng septic tank as
approved by the Boats of Health.
Sewage backup or breakout or higk static water level observed in the distribution box Is due to broken or obstructed pipe(sl
or due to a broken.settled or wreves distriladion box. The sysm wN pass inspection if(witb approval of the Board of
New".
broken pipets)are replaced
obstruction Is removed
distribution box k Mwlled or replaced
The system required pun bV more then law tines a Veer dus M broken or obstructed ppeW. The system will pass
kupecdon H(weidr approval of the Bard of Healthl:
broken pipets)are replaced
obstruction b snowsd
revised 9/2/98 tsp2e(11
SUBSURFACE SEWAGE pEpOSAL SYS'TE]N NSPECTION FORM
PART A
CE11T1FICAIION lconorswdl
PtopaatV Address:
Owner:
Oats of btspeceorr:
G FURTHER EVALUATION 6 REGURMBY THE BOARD OF HEALTH:
Cond om exwt which require fuudm wAiuukn by der Board of Health in ardor to duerrninra if Ills system a hthw to protest tM
.pubic haddt.sally and dte ertviranrettt- -
11 SYS W rVaL PASS UV&M BEARD OF HEALTM Ok713RNOW N ACCORDANCE VMM 310 CMR 15.'M(IN"THAT THIS SYSTEM
6 NOT PUNCTtf"NG N A MAXNW vooW VIAL PROTECT THE PUSLiC HFALTM AM SAFETY AM MM 6WIRON1MEN1T:
Casspod er phry b whNn 50 teat of Surface water wedod or a salt marsh.
Caaspoal or peM is widin 5o feet of a bom-4 vs9ed
a SYSTEM tNNl FAIL tRrLEss THE:BOARD OF HEALTH(AND PUBUG WATER SUPPUM IF ANYI DETE RNWtEs THAT THE SYSTEP M
FWCTlomG N A W1I�IMT PROTECTS IM PUBLIC HEALTH AND SAFETY AND THE ErWtONMEffT:
The systern has a s"ft tank and s o�Pt��4SAM and the SAS is within 100 feet of a surfsce water supply or
tribunary to a surface water supph• and do SAS is within a Zone 1 of a pubik water Supply,wall.The system has >�teak and Sour absorption rn nand the SAS is vAA do So taet at a private water supply well. .
The system has a septic tam and sal absorption systan
T1re system>rs a septic tank and SO absorpti �sstd the SAS is less dram 100 bet but 50 fast or awre from a
phraoa water aupph ra•uslass•well rater seal- I for caliiform.baeomia and valadM meanh compounds indicates that M
well is free from pOWAon free drat fan—11 and doe presanea of artotourta aitr R void!.
M and nritrato uitroBen b efpral m or less
than 5 p Modrod used 10 deternine dstarroe lapprdOn urs
pn.
31 OTHER
revised 9/2/98 ftr3of11
5
SUBSURFACE SEWAGE DISPOSAL SYSTDO NSPECTWN FORM
FART A
CERTIFICATION(cermraedl
PropwtV Address:
Owner:
Date of Mp o p li n
CL SYST91 FAILS:
/You must indkats either-Yes'or-Na- to each of the follo In
Ng:
/-_ I haw determined that one or more of the following failure conditions exist as desenI in 310 CM IL303. Thor bash for this
dataerrnatiarh is identified below. The Board of Health should be eahteetad to debmin what will be necessary to Correct the failure.
Yes No
Backup of sewage into faaTitl/or system component dui to an evarlo or clogged SAS or cesspool.
Discharge air pondng of affluent to the surface of the ground or surface wato dare to an overloaded Of dogged SAS or
cesspool.
Static Squid level in the distribution bo:above mulct invert An to an overloaded or dogged SAS or cesspool.
Liquid depth in cesspool is less don V below inert or own&&@ volume is less than 112 day how.
Required pumping more than 4 limos in the last year NOT dui to dogged or obstructed pipMs).
Number of times pumped—;
Any portion of the Sol Absorption System,cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is withirh 100 feet of a surface water supply armiluory to a aurface wench supply.
_ Any portion of a cesspool or p*4y is witNnh a Zone 1 of a pubic well.
Any pardon of a cesspool or privy is withlh 50 feet of a privela now supply well.
Any portion of a cesspool at pdv#is logs-don 100 feet but greeter don 50 feet from a privaoa wager supply wall with no
acceptable water quality an 1ydo If the well hes been arelpad is be aooaI I la.attedh Copy of well Water analysis for
Coifam bacteria.valadle organic ce polm w a orda nhftrogen teed citrate r oft ogwh.
E LARGE SYSTEM FAILS:
You nest indicate either'Yes' or'No' to each of to following:
The following criteria apply to large systems in addition to the criteria above:
N�A The system serves a faciRty with a design lbw d 10.000 gpd or greater Large SystarM and date
system
is•significant bleat to public
health and safety and the arwiren ment because ono or more of ON logexistg conditions exist
Yes No
the system is within 400 feat of a surface drinking water supply
do system In widde 200 feet of a tributary to a surface dui d&-water supply
the system is located in a nitrogen sensitive shoo(Interim Yileihead Protection Ana-IWPA)or a mapped Zane N of a pubic
water supply well
The owner or operator of any such system shd upgrade the system in accadrnce with 310 CMR 15.304(2). Plane Consult the local regional
office d the Department for further iniamstion.
revised 9/2/98 Par 4of11
I
. SUBSURFACE SEWAGE OtSPOSAL SYSTEM IMSPECTM FORM
PART B
CHECKLIST
Proper"Address:
OWE
Oaf of kapw"M
Cheek if the following have bean done.YOU must a rya or'No' as a each of*a feftwbg:
Yaj No pump I �r radon was prwAded by the owner.occuPant.or Board of Hedit
JCS boor CoivYaf
wanks and tine sysaao has
Nona of the system a hens ban phMnpad for m Nast two �y or a pert of this
rates during that period. Logs volumes of water hove net been introduced Into the syatatn
Inspection.
As built pla have bean obtairh d and examined. Now if trey we not available with NIA.
ns
The facility or dwelling was ioapeoted for signs of$*wage back-up-
TM system.does not racalve non-swimy of industrial waste flow.
The site was inspected for signs of breakout.
—t — the site.
excluding dw Sal Absorption System have been located on
_✓ � All system eomponants. ,.
_ Pa^ad•and the interior of the septicwnk was irhspe¢tod for conuftion of baffles
The sepde tank rnenlhales war*uncovered'°
J` or toes.mots"of cwwvuetb^' •depth of liquid-depth of sludge•depth of sewn.
Sol Absorption System
The she and location of to Sol the sib has been determined based on:
Existing information.For example-Plan at B.O.H.
petwrnh sd in the field of any of dw farlme criteria related to Hart C is at issue.approxNution of Qistanea is anaoeeptablel
—•� — (16.30201ibi1 -
The facility owner land occupants•if afferent from own*rl were provided
with bdermsdon an dw pmpar bane of
SubSurface Oisposai Systans.
Par S of 11
revised 9/2/98
• t
SUBSURFACE SEWAGE DISPOSAL SYSTEM WSPECi10N FORM
PART C
SYSTEM IMM"MN
Property Address:
Owner
Oats of Inspection:
FLOW CONDmoNS
RFSDefT1AL:
Design 11ow• 1/0 a.p.dJbedro m
Number at bedrooms(design):,1 Number of bedroans lecdl: 3
Tod DESIGN flaw-3 3 o rr p p
Number of wren!residenb:_a
Gad ps grinder(yes or no)„"
Laundry(separate system) (w or nol:_64 If yes. separate irwpeadon required
Laundry system inepmad (yes or
Seasonal use lyee or no)_"
Water meta readings.M avaaabb am two year's usage(gpd): N A
Sump Pump(yes or nol: Jo
Last data of occupancy Y R Fsc^-r
COMIMER
Type of establishment•.
Design flow: and 1 Based on IS.203)
Basis of design flow
N /k Grove"trap present:(yes or no)_
Mrdustrid Waste Holding Tank present-(Ves or no)_
Non-sanitary waste discharged to dw rdle 5 system:(Yes or nol
Water rneter readings.if available•
Last date of occupancy:
OTHER:(Describe)
'.test date of occupancy:
GENERAL NFORYATION
PUMPWG RECORDS and of ird, aioa:
03A RV -7M F3 c t
System pumped as pert of inspecdon:lyes or no)&O
If yes.valunw pumps&_ X aaBons
Reason for pumping: �(
TYPE,.W SYSTEM V
�_ Septic tank/distr3udon lwsfad absorption system
Single cesspool
Overflow cesspool
Privy
Shared system(yss or no) III yes.Mach previous inspection records.if any)
VA Technology ate.AM*copy of up to data op do and nnwintenwnes conrtract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all conmoonem.data installed lif known)and sours of information:
Sewage odors detected when arriving at tine ske: (yes or no)_,fL1dA1C-
revised 9/2/98 fne6of11
. SugSURFACE-sEWAGE DISPOSAL SYSTEM WSPECTICN FORM
PART C
SYSTEM NFORMATMM IC000110104
property addrm:
ow"on
Date of lo:pecdor:
BUI DM sfveel:
(1.E on site plan)
Nr Dapffi below grade: other le
Materiel of cwwuucbw_east iron_40 we_ xp
DbMwme Iran pivaa VMW a**wad or suction fine
pisnrater
Dl r nelorits:leondidon of jok=.varrorrg,evidence of leakage.ate.)
SEPTIC TANK:1/
(locate on site plan)
Depth below Bede: ! / natal Frbaglsas Pclyed�ykm otlm1e:plein)
Material of consoucdon: ✓ fee_
Is age confirmed by Cartif sto of Compliance_IYesMo)
K tank is Metal.�age— .
pinranaia+s: n
5 7 x L S G
Sludge depth:!
Distance from top of sludge to bottom of outlet too a baffle:
Sean thickness: / _
from top of scum to top of outlet Its a baffle-
Distance
Dytenee born bottom of scam to bottom of outlet tee or baflle:�_
ow dimensions wars deu mined: I f y A•L :
l ar v'
Comments: of krvel in relation m outlet kmCrt.strr cmW integrity.
Itaeaerrrso datiorr for prenpw4 eon6lion of WN and ouWt tees or bsMrls.depth liquid ` _ v
evklerrce of leakage.etc.) •r
GREASE TRAP:
-pace"an site plan(
Matto ' M Constsuetion:_senoras meta!Fbaglasa �below WWO: 'Po111etlMene otlrsrlexdeinl
pimarsions: _
Distums from top of swop to taip of cutlet tee or b M:_
olarrc.treat bottom of jo"to bottom of OWN tee or baffler
Date of last pumping: .
Comments:
• eondtion of allot and outlet tees a bafRes.depth of Ilquid level in nletb to outlet irrvort.structural irrtagritY•
Ireroo^for�npirg, .
evidence of leakage.atc.)
I
revised 9/2/98 Pat*7or11
SUBSURFACE SEWAGE DISPOSAL SYSTEM NISPECTION FORM
PART C
SYSTEM NFORMATION lcondmreA
Property Address:
Oamer.
Oats at hnipecdon:
TIGHT OR HOLDING TANIL- Rank must be purnpad prior to,or at Um of,intpeedon)
NocaRo an site plan)
10111orth hello grade:
&%tw"of eoratrutdon. . tr col Fibw&m Pof+Cknonskmupedll�lan._otlrarleaplainl
: --
Design flow: fa@Nonddn
Warm present
Alarm bvel: Alarm in wonting order:Yes Ne
Oats of previous pumping:
commeets:
!condition of Wet tee.eondidon of alarm and float awilehes.etc.!
OISTRMUTM sox. ✓
floeete on site plan) _
rI -
Depth of ksAd level above outlet invert:
Comments:
(mote it level and dzukutisn is equaL avidance of acids cm"Wvw.Owdw ee of Nakage irM or out of box.ate.)
is r C t j2 r R,i T i0.y S F d a A e � a I A R42
i Fw ICi4 r'E
,
MAP CHAMB61:_
(loc:nte on site plan)
A/1,6ps Pwn in working order:(Yes or Nol
Al rm in working order(Yea ar Nai
Comments:
mote condition of pump chamber.eondidon of pumps and apprrtonarwas.etc.)
revised 9/2/98 r�raetu
' SUBSURFACE SEWAGE DISPGSAL SYSTEM&jSPECT M FORM
PART C
SySIy tNFORMATWH IGOW U"
Plep•�►Add m—.
Dow of =
SOaL ABSORPt>ON SYSTEM 1---AC Uw��be��fod by non4na" vo n+edadsl
ft"to on eke Plan4 if possible:gem
K not located.Mown"
'j'Z
TV": 2 E� 8 c oe I
beding Pis.nunbw:_
baeti*ctAmbers.nab*:_,
ue
Wading aenehes nupfw.bmgth:
bathing Bolds.nuoba.
overaow cesspOW•mxnbar:
AfEemetiw systern: .
Nome of Techna cgll:
e°'""""ts' feau...br l of poang• damp s0il.canditicn of vegetation.etc.i ► F.41 c o F2 F
loofa condtion of soa.signs of AvdreufK 17ow
L
j� A
Owl
Number
Number wW configursdcm:
1� ,epth-too afIqLid to Wet
Jop*of scads lever.
oop*of scan lever.
ohnonsions of cesspool:
Mstsdds of consbucdan•
Imcadon of groundwater. i
Inflow(cesspool must be pumped pun ow inspection
COS: faRwe.level of poeedng.common of vegstatio% *=.i
p ots eondtiom o1 sa1.algns o1 ItydrauGc
o0coft an sic phnl
Meaews of eonsaucdon:
depth of soaes:_
com"W"Vw tail►oe.bvd of oon&V.cwWhWn of vegetedw% etc.)
Mote a end en of sM.signs of l *suft
fate 9 of it
revised -9/2/98
SUBSURFACE SEWAGE OWWAL SYSTEM MWECnON FORM `
PART C
SYSTEM INFORMAT M leonlimeA
PrapwtV Addnas:
O"nr:
Oau�ai t+�ttiore
SKETCH OF.SEWAGE DISPOSAL SYSTEM
in km%IM to at how two pannwma alatanea landtnarit:or bmm*wnuln
loeab ON wars widwi IOW PAcoa wham pub k mom supply mmm info houW
1
r20A/^r �
M ��c�f ECL 5 . c� ►'�y
revised 9/2/98 Face leotit
SUBSURFACE SEWAGE DVWMAL SYSTEM INSPECTION FORM
PART C
SYSTEM RAVIIMATION(CwWnw6A
ltiopawW Address:
owner.
On"d lrspoedon:
NRCS Repoli rterne
"Type_
Typical depth to WMAdwater
USES Data webda vtiesd
Obw,eion welt choked
GrowWwater depth: Shaloow Modest•
SITE EXAM Slope
SwInce water
Check Calla.
Shallow wags
> i3
Estirnetad Depth to Groundwater_'Oat
Please indicate all *methods used to determine High Groundwater Bowdon:
Obtained Womi Design Plena on record
l/ O/bserved Site(Abutting propow".observation hole.basement sump etc.)
Determined from local conditions
Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local'excavators.instillers
Used USGS Data
Describe how you Wished the W*h Groundwater Elaradom lYusl tw )
. _ . •�£s.� l�oC�. o�v G�c�T �.�ft,v Sirf$G� �. O, ff. i
revised 9/2/98 rate It of11
Please read this notice
Purpose: The information in this report is based on visual inspection of the
listed property. This does not mean that that every defect was discovered or
uncovered This report does not offer nor imply a warranty to any defect to
the operation of this system. The process is to visually inspect, as much as
possible, the components of the septic system and to determine if this system
meets the criteria outlined by this report concernia Title Five regulations.
S gala
This information is based from the conditions noted at the time of the
inspection. There is no indication given as to the remaining useful years or if
the engineered design flow is at present use of this dwelling. The use of this
information is with the understanding that the above conditions are integral
to this report whether it is from the buyer or sellers position. A copy of this
report will be kept by me and is a available to all parties concerned
If you require further information, please contact me directly at any time.
Thom is J; R 08ERTs l-711 - a • O
� � _ �3 4
T as?Ec:rc;R
ts.v14•d 04/23/271 Page 10 ee 10
�d TOWN OF BARNSTABLE
CCATION 04V SEWAGE # �" //5
VI:LAGE y ASSESSOR'S MAP & LOTS '
INSTALLER'S NAME&PHONE NO. 0"A AJ rJ2CJv'dI--T;:e- Vr
SEPTIC TANK CAPACITY c -f!S
LEACHING FACILITY: (type)naiLve r.s .3 (size) d X r Q
NO.OF BEDROOMS
BUILDER OR OWNER A 4 5 Se
PERMIT DATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by `"
N
f
"!Q
O
'k
J
s
C'
� . 0A
No. Fee, 1
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF. BARNSTABLE, MASSACHUSETTS
ZIppYtcation for Mis�pom *p5tem Cow5truction Permit
Application for a Permit to Con ( )Repair( )Upgrade( )Abandon( ) O Complete System ❑Individual Components
Location Address or Lot No. �/�✓�+^ � 5 *f/ Owners Name,Address and Tel.No.
Assessor's Map/Parcel
C�Flo O
Installer's Name,Address,and I�TeT—No Designer's Name,Address and Tel.No.
_RWCOA1.5 4CIC 0 J A)C_
Type of Building:
Dwelling No.of Bedrooms 4" Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow c �- gallons per day. Calculated daily flow gallons:
Plan Date — / —�' Number of sheets Revision Date
Title
Size of Septic Tank 1j<00 Cal Type of S.A.S.
Description of Soil 00
Nature of Repairs or Alterations(Answer when applicable)
Date last'inspected:
Agreement: _
The undersigned agrees to ensure the construction and main nance of the afore described on-site sewage disposal system
in accordance with the provisions of the vironment Code and not to place the system in operation until a Certifi-
cate of Compliance has been edb u t ' o ea
Signed Date —
Application Approved by 1 Date —
Application Disapproved for Re following reasons
Permit No. Date Issued
y.._
No. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:Vi
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS Yes
2pprication for Mitpool *pgtem Construction Permit
't Application for a Permit to Construct'( )Repair( )Upgrade( )Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No. /O G, e�r_ 5 R�( Owner's
Name,Address and Tel.No.
Assessor's Map/Parcel
fo 70
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
- Type of Building: }.. ��//
i Dwelling No.of Bedrooms e,Q ki sr5 A'S Lot Size sq. ft. Garbage.Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons. r r
Plan Date Number of sheets Revision Date
Y Title
Size of Septic Tank <00 Cj Type of S.A.S. I
Description of Soil
Nature of Repairs or Alterations(Answer when applicable)
w
i
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and main en
of the afore described on-site sewage disposal system
in accordance with the provisions o i of the vironment Code and not to place the system in operation until a Certifi-
cate of Compliance has been Kued b t ' o ea
~ Signed Date
Application Approved by 1 Date —
Application Disapproved for Re following reasons 1
> • ,
4_ Permit No. Date Issued
----------------------------------`THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
THIS IS TO C FY, at the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded( )
Abandoned( )by C OIV Y_r u CIL i e U MLI c—
at 0 P l� GJJ2 f 0 e. has been constructed in accordance
with the provisions o,Title 5 aud the for isposal S em Construction Permit No. 79—ZI, dated
Installer / �.� rue` ;JC Designer Dal
The issuance of thi permit shall no a ,onstrued as a guarantee that the system ill u tion as designed.
Date Inspector r
----------------------------------------
No. c - // Fee 3
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE, MASSACHUSETTS
Mi.5pogar *p!6tem Construction Permit
Permission is hereby granted to Construct( )Repair( )Upgrade )()Abandon( )
System located at 6 c G
P
and as described in the above Application for Disposal System Construction Permit.The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of this permit.
Date: off- ~ �i Approved by �.
Commonwealth of Massachusetts
Executive Office of Eiiviroiunental Affairs
Dept. of Environmental Protection
John Grad
One winter Street,Boston,Ma. 02108
D.E.P. Title V Septic Inspector
P.O. Box 2119
1t�MA 02536
WILLtAM F.WELD g��564-ti813
Governor "
ARGEO PAUL CELLUCCI
Lt.Governor Y•' f /�/�
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR 91/
PART.A'
CERTIFICATION " 107�fF?,y�,,p St 1
T tTt y e«e s � ",✓p'vT 9y�
S
Property Address: 108 Mitchel's Way Hyannis Address of Owner: Fiol96�`
Date of Inspection: 11/1197 '' (If different)'
Name of Inspector: John Graci Paula Phillips Bell
I am a DEP approved system inspector pursuant to Section 15'.340 of Title%(310 CMR 15.000) 9
Company Name,Address and Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and ,
maintenance of on-site sewage disposal systems..The system:
x Passes This Inspection Is based on criteria dented In This V
_ Conditions Pa es code 310 CMR 16303.My findings are of how the system Is
performing at the time of the Inspection.My Inspection does
_ Needs Filter
ther aluation By the Local Approving Authority not Imply any warranty or guarantee ofthe longevity ofte
Fells septic system and any of Its components useful life.
Inspector's Signature: ° Date: ivv97 "
The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,iUappiicable and the approving authority.
INSPECTION SUMMARY:
Check A, B,C,or D:
A] SYSTEM PASSES:
x I have not found any information which indicates that the system violates any of the failure criteria
defined as in 310 CMR 15.303, Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY.PASSES:
One or more system components need to be replaced or repaired. The system,:upon completion ,
of the replacement or repair,passes inspection..
Indicate yes,no,or not determined(Y, N, or ND). Describe basis of determination in'all instances. If "not determined",explain why not
The septic tank is.metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
CoMpliance(attached)indicating that the tank was installed within twenty(20)years prior to the date of the inspection, or.
the septic tank,•whether or not metal, is,cracked,.structu rally unsound,shows substantial infiltration or exfiltration, or tank
failure is imminent.,The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
r as approved by the Board of Health. A'
(revised 04127S7)
One Winter Street *,Boston,Massach6settss02108 •„ FAX(61,7)556-1049 • Telephone(617)292-5500
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
,... PART A
CERTIFICATION(continued):
Property Address: log Mitchers Way Hyannis `
Owner: Paula Phillips Bell
Date of Inspection:11r1r97
_ Sewage backup or,hreakout.or, hiah.static w,ater'level obsenred.in.the distribution box is due to a broken.
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if
(with approval of the Board.of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed
distribution box is leveled or replaced
_The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the.Board of Health):
broken pipe(s)are replaced
obstruction is removed
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF.HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the.public health,safety and the environment. 5
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of bordering vegetated wetland or salt marsh. L
f
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surfacelof water supply or tributary to a surface water supply.
The system has.a septic tank'and soil absorption system and is within a Zone 1 of a public watersupply well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
'The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
Tess than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other'
D] SYSTEM FAILS:.
You must indicate either"Yes"or"No"as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in
310 CM,R 15.303.,'The basis for this determination is identified below. The,Board of.Health should be '
contacted to determine what will be necessary to correct the failure.
Yes No x
Backup of sewage in facility or.system component due to an overloaded or clogged SAS or
cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
SAS is in hydraulic failure.
(revised 041211971
s � ;
4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 109 Mitchel's Way Hyannis N
Owner: Paula Phillips Bell
Date of Inspection:1111197
D]SYSTEM FAILS(continued)
Yes No .'
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
— Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). p
Numbers of times pumped >
Any portion of the Soil Absorption System.-cesspool or privy is below the high groundwater elevation.
— Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion ofa cesspool or privy is within`a Zone 1 of1a public well. `
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than,100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for
coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either"Yes"or"No"as to each of the following: ,
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or-greater(Large System)and the system is a significant threat to.
public health and safety and the environment because one or more of the following conditions exist:
Yes No „
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)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and`6.00. Please consult the local regional office'of the Department for further information.
414
trevlsed0412T1971 ; ,
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST u
Property Address: log Mitchers Way Hyannis
Owner: Paula Phillips Bell
Date of Inspection:'1'lltl97
Check if the following have been done:YOU must indicate either 'Yes"or"No"as to each of the following:
_x_ Pumping information was requested of the-owner, occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during:that period. Large volumes of water have not been Introduced Into the system recently or as part of this
inspection.
x 'As built plans have been obtained and examined. Note'if they are not available with N/A. '
x — The facility or dwelling was inspected for signs of sewage back-up.
x The system does not receive non-sanitary or industrial waste flow.
,c_ —. The site was inspected for signs of breakout.'
x All-system components,excluding the Soil Absorption System,have been located on the site.
x The septic tank manholes were uncovered, opened,and the interior of the septic tank was inspected
for condition of baffles or tees,material of construction, dimensions, depth of liquid,depth of sludge,depth of scum. f
x The size and location of the Soil Absorption System on the site has been determined based on
— The facility owner(and occupants, If different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x Existing information: Ex.Plan at B.O.H.
x Determined in the field(if any failure.c triteria related Par C is at issue, approximation of distance is
— — unacceptable)115.302(3)(b)1
irevlsed 0411Tl9TI
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 108MItchers WayHyannls
Owner: Paula Phillips Bell
Date of Inspection:1111197
A' ><._' FLOW CONDITIONS
,
RESIDENTIAL:
Design flow: 9•P d./bedroom for S.A.S.
Number of bedrooms: 3
Number of current residents: o
Garbage grinder(yes or noj: No
Laundry connected to system(yes or no): No
4
Seasonal use(yes or no): No A `< s
Water meter readings,if available(last two(2)year usage(gpd). ,
House has town and well water,wag water to be used only for outside watedng of the property.
Sump Pump(yes or no): No
Last date of occupancy: Na "=
COMMERCIAL/INDUSTRIAL. t,••
Type of establishment: nia
Design flow:0 gallons/day
Grease trap present:(yes orno) No
Industrial Waste,Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system::(yes or no) No
Water meter readings,if available: We
Last date of occupancy: nra
OTHER:(Describe)'rva `
Last date of occupancy:: :M,r
GENERAL INFORMATIOW
PUMPING RECORDS and source of information:
Na
System pumped as part of inspection:(yes or no)No
If yes,volume pumped:0 gallons, ;
Reason for pumping: Na
TYPE OF SYSTEM
x Septic tank/distribution box/soil absorptions system
Single cesspool
Overflow cesspool t ,
Shared system(yes or no) ( if yes,attach previous'inspection records,if any)
I/A Technology etc.Copy of up to date contract?
Other:
r• APPROXIMATE AGE of.ali components,date installed(if known)and source`lnformation:
Approximately 10 years.
Sewage odors detected whenarriving at the site: (yes or no) No
(revlsed 04127187)
U ` -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 108 Mitchel's Way Hyannis
Owner: Paula Phillips Bell
Date of Inspection:11ff1►97
SEPTIC TANK: x „
(locate on site plan)
Depth below grade: 2 6
Material of construction:x concreate metal FRP Polyethylene_other(explain)
If tank is metal, list age o Is age confirmed.by Certificate of Compliance No (Yes/No)
Dimensions: [e'6'•H5•7••w4-10
Sludge depth:t" r011
Distance from top of sludge to bottom of outlet tee or baffle: 26
Scum thickness:0 ,
Distance from top of scum to top of outlet tee or baffle:6"
Distance form bottom of scum to bottom of outlet tee or baffle:0 .s,
How dimensions were determined: Measured
Comments:, m
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)'
Septic tank and all componenteare structurally sound.Recommend pumping system every two years for maintenance.
9 i
I
GREASE TRAP ;.
(locate on site plan)
Depth below grade: nia
Material of construction: concrete . metal FRP_Polyethylene—other(explain)
Dimensions:Dimensions:_n1a
Scum thickness:rda
Distance from top of scum to top of outlet tee or baffle:'nia ro'
Distance from bottom of scum to bottom of outlet tee or baffle: Ne'
Date of last pumping;,
Comments:
(recommendation for pumping,condition of inlet and'outlet tees or baffles, depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage, etc.)
We "
BUILDING SEWER:
(Locate on site plan)
Depth below grade:.3
Material of construction: cast iron x 40 PVC other(explain)
Distance from private water-supply well or suction lin0o-
Diameter: 4"_
Qemments:(conditions of joints,venting,evidence of leakage,etc.)
(revised 0427)97)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: log Mitchel's Way Hyannis ,
Owner: Paula Phillips Bell
Date of Inspection:1111197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Na .: s
Material of construction:_concrete_metal_FRP_Polyethylene_other(explain)
Dimensions: nia
Capacity: Na gallons s.
P Y�
Design flow: Na gallons/day
Alarm level: nia Alarm in working order?_Yes No
Date of previous pumping:
Comments:
(condition of inlet tee,condition of alarm and float switches,etc.).
Ne .
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet'invert'Na }
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence of leakage into or out of box etc.)
c
Na
_ s -
PUMP CHAMBER:
-
(locate on site plan)
Pumps in working order.(yes or no)Nc ,
Alarms in working order(yes or no)_Ye:
Comments:
(note condition of pump chamber,condition of pumps and''appurtenances,etc.)
Na
(revised 04127S7)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
'PART C
SYSTEM INFORMATION (continued)
Property Address: tog Mitchel's way Hyannis a c
Owner: Paula Phillips Bell
Date of Inspection:7t1t►g7 v
SOIL ABSORPTION SYSTEM(SAS):x
(locate on site plan,if possible;excavatio rL n not required,;but may be approximated by non-intrusive methods)
If not determined to be'present,explain:
,
We - -.
Type.
leaching pit ,.number: i pw gallon leach pit
leaching chambers,numberf rd..
leaching galleries,number: rda
leaching trenches,number,length: rda
leaching fields,number, dimensions.•nla ,
overflow cesspool,number:nla Name of Technology' nra
Alternate system: nla — ''
Comments:(note condition of soil;signs of hydraulic failure,level of ponding, co vegetation,etc.)
ndition of ve
The leach pit Is structurally sound and functioning properly.It was empty at the time of the Inspection.Pit has not had more than 2.5"of water In It.
CESSPOOLS:_ F
(locate on site plan)
;P
Number and configuration: n1a
Depth-top of liquid to inlet invert: n1a
Depth of solids layer. We
Depth of scum layer: We
Dimensions of cesspool:' We.
Materials of construction: rda- t:
Indication of groundwater: We. (`
inflow(cesspool must be pumped as part of inspection)
n!a
Comments:(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
Na ,:
PRIVY:_
(locate on site plan)
Dimensions: ma
Materials of construction`Na
Depth of solids: n1a _ -
Comments;(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.)
-. (reylsed0427197)
SUBSURFACE SEWAGE DISPOSALSYSTEM,INSPECTION FORM
PART C
SYSTEM.INFORMATION(continued)
104 Mitchel's Way Hyannis
Paula Ph
illips P
s Bell
1111197
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to.at least two permanent references, landmarks or,benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
:brc� LQj�
A
no
_ C i I 0
(rwlved427W) Pat• 9 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
y SYSTEM INFORMATION(continued)
108 Mitchel's Way Hyannis
Paula Phillips Bell
v
1111197
Depth of groundwater.
Please indicate all the methods used to determine High Groundwater Elevation:'
Obtained from design plans on record:
Observation of Site(Abutting property,observation,hole, basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping,records -
Check local excavators, installers
x Use USGS Data
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
of 10 `
(revised 04f2T18T)
, w
11H*E� , Town of Barnstable
Department of Health,Safety,and Environmental Services
BARNSTABLE,
9� ��r Public Health Division
i°rFn n►x�°i . 367 Main Street,Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
FAX: 508-790-6304 Director of Public Health
Paula Phillips Bell /� I- December 2, 1997
104 '
L ke e-- j Wt s c s,-S ac)
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 104 Mitchel's Way, Hyannis was inspected on
November 2, 1997 by John Graci a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• Overflow cesspool is less than 50 feet to wetlands
You are directed to hire a licensed professional engineer (PE) to design a system that will
bring the septic system in compliance with 310 CMR 15.00, The State Environmental
Code, Title�5 ,yyithin twenty-one (21) days of your receipt of this letter.
You.are also,directed to hire a licensed septic system installer to install the system
components,within forty-five (45) days of your receipt of this order.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface ofthe ground, or in to surface waters.
An person aggrieved b an order issued b the local approval authority may appeal to
Y p gg Y Y Y pp Y Y pp
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
frtas-�A. McKean, R.S., C.H.O.
t�gerit"Of the Board of Health
ti •_
t' 7-7 -�oSs �/�. ' 77 /- 67a�
5L - -
��► Town of Barnstable
Health,Safety,and Environ
mental Services
.�. Department of He y,
'"� Public Health Division
9 t639.
��FO M►d 367 Main Street,Hyannis MA 02601
Office: 508-790-6265 Thomas A.McKean,RS,CHO
Director of Public Health
FAX: 508-790-6304
Paula Phillips Bell December 2, 1997
104 Mitchel's Way
Hyannis, MA 02601
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5.
The septic system owned by you located at 104 Mitchel's Way, Hyannis was inspected on
November 2, 1997 by John Graci a Massachusetts licensed septic inspector.
The inspection of your septic system showed that your system has failed under the
guidelines of 1995 TITLE 5 (310 CMR 15.00).due to the following:
Overflow cesspool is less than 50 feet to wetlands
You are directed to hire a licensed professional engineer(PE) to design a system that will
bring the septic system in compliance with 310 CMR 15.00, The State Environmental
Code, Title 5 within twenty-one (21) days of your receipt of this letter.
You are also directed to hire a licensed septic system installer to install the system
components within forty-five(45) days of your receipt of this order.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
mas�AMcKean, R.S., C.H.O.
Agent of the Board of Health
Town of Barnstable
..� Department of Health, Safety, and Environmental Services
B"'MAM Public Health Division
y MA98.
Eon 367 Main Street, Hyannis MA 02601
Office: 509-790-6263 Th mn A.McKean,RS;CHO
FAX: 509-790-6304 Director of Public Hearth
TO: to, 6t T �� S
DATE: C ZAAA
ORDER TO COMPLY WITH 310 CMR 15.00, THE STATE ENVIRONMENTAL
CODE, TITLE 5. /
The septic system owned by you located at Mi (� ci'mm
was inspected on Ab4-_ ? by -�I 6 c a Massach etts mensed
septic inspector.
i
The inspection of your septic system showed that your system has failed under the
guidelines o 1995 TITLE 5 (310 CMR,'15.00) due to the following: � n�
You are directed to hire a licensed professional engineer (PE) to design a system that will
bring the septic system in compliance with 310 CMR 15.00, The State Environmental
Code, Title 5 within twenty-one(21) days of your receipt of this letter.
You are also directed to hire a licensed septic system installer to install the system
components within forty-five(45) days of your receipt of this order.
You are further directed to maintain the system by hiring a licensed septage hauler to
pump the septic system to prevent discharge of sewage or effluent into the buildings, onto
the surface of the ground, or in to surface waters.
Any person aggrieved by any order issued by the local approval authority may appeal to
any court of competent jurisdiction as provided for by the laws of the Commonwealth.
PER ORDER OF THE BOARD OF HEALTH
Thomas A. McKean, R.S., C.H.O.
Agent of the Board of Health -
�.nn�m���e« ..•
r
S-11\ Commonwealth of Massachusetts
Executive Office of Env' io ital Affairs
"°Dept. of Environ
John GI'acl
One winter Street,Boo a. 021 p•E•p:Title V Septic Inspector
P.O. Box 2119
*01 Teaticket,MA 02536
rod - (508)564-6813
�
WILLIAM F.WELD ,j/Q f� ® f� �f* yFq�y�9ys ,'99�
Governor ®
ARGEO PAUL CELLUCCI F
Lt.Governor ;
SUBSURFACE'SEWAGE D S,PO ALSYSTEM� SP CTION FORM 1�
C R IFICA 1�0
Property Address:s�'104 Mitchel's Way Hyannis 4 Address of Owner:
Date of.lnspectlon~11-11197- (if different)
Paula Phillips Bell
Name of Inspector: John Graci 7
I am a DEP approved system Inspector pursuant to Section 15.340 of Title°k(310 CMR 15.000) T00 b� ® y�1p99�
Company Name',Address and Telephone Number.
CERTIFICATION STATEMENT a ow is true,accurate
I certify that I have personally inspected the sewage disposal system at this address and that the informa o .
and complete as of the time of inspection: The inspection was performed based on my training and experience a proper function and
maintenance of on-site.sewage disposal systems. The system:
4
This inspection la based on criteria donned In Title V -. .
Pa5585 code 310 CMR 16.303,My findings are of how the system is
Condition y,P^ Ses performing atthe time ofthe Inspection.My Inspection does
Needs F the valuation By the Local Approving Authoritynot Imply any
septic system and any of Its components useful life..rranty or guarantee of the longevity of the
x Fails ,
Inspector's Signature:
Date 1112197
The System Inspector shall ubmit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this
inspections. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority.
INSPECTION SUMMARY: -
Check A, B,C,or D
A] SYSTEM PASSES: .
_I have not found any,information which indicates that the system violates any.of the failure criteria
defined as in 310 CMR 15,303. Any failure criteria not evaluated are indicated below.
COMMENTS:
B] SYSTEM CONDITIONALLY PASSES:
One or more system components need to beE�eplaced or re aired. The system,upon completion
' p Y
of the replacement or repair,passes inspection. '
Indicate yes,no,or not determined(Y. N,or ND) Describe basis of determination in all instances. If "not determined",explain"Why not.
The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
led within twen 20)years prior to the date of the inspection,•or
• that the tank was
instal ty
,• — compliance(attached)Indicating
the septic tank,whether or not metal,is cracked,structurally unsound,shows substantial infiltration or exiiltratlon,or tank
failure is imminent.The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
is approved by the Board of Health.
(revised 04127)97)
-5500
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292 '
. I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A .
CERTIFICATION (continued)
Property Address: 104 Milchers way Hyannis .
Owner:
Paula Phillips Bell
Date of Inspection:1tnJg�
I
_ Sew.aae backuD or,hreakout or hiah.static water level observed.in.the distribution box is due to a broken. r
or obstructed pipe(s)or due to broken,settled or uneven distribution box.The system will pass inspection if '
(with approval of the Board of Health). Describe observations:
broken pipe(s)are replaced
obstruction is removed.
distribution boz is leveled or replaced
_The system required pumping more than four times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
broken pipe(s)are_replaced'
obstruction is removed-,
C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
_ Conditions exist which require further evaluation by the Board of Health in order to determine if the
system is failing to protect the public health,safety and the environment:; {°:y
1) "SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS '<<
NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
Cesspool or privy is within 50 feet of a surface water"
_ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH(AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES
THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and is within 100 feet to a
surface of water supply or tributary to a surface water supply.
_ The system has a septic tank and sot(absorption system and is within a Zone 1 of a public watersupply well.
stem and is within 50 feet of a private water supply well.
The system has a septic tank and soil absorption sy
The system has a septic tank and soil absorption system and the,SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that
the well is free from pollution from that facility and the presense of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm. Method usedto determine distance (approximation not valid)
3)Other
DI SYSTEM FAILS: t
You u must indicate either"Yes"or"No"as to each of the following: i
x I have determined that the system violates one or more of the following failure criteria as defined in
310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be
contacted to determine what will be necessary to correct the failure..
Yes No
Backup of sewage in facility or system component due.to an overloaded or clogged SAS or µ
cesspool,
x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged
cesspool.
x_ SAS is in hydraulic failure.
(reylsed 04r17)97i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
CERTIFICATION (continued)
Property Address: 104 Mitchel•s Way Hyannis
Owner: Paula Phillips Bell
Date of Inspection:1111197
' r
D]SYSTEM FAILS(continued)
Yes No
X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.!
X Liquid depth in cesspool is less than 6"below invert•or available volume is less than 112 day flow.
' 4 ,
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
— -- Numbers of times pumped - °
— X Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation.
— _X• Any portion of a cesspool or privy is within 100 feet of a surface'water supply or tributary to a surface water supply.
x Any portion of a cesspool or privy is within a Zone 9 of a public well.
—X Any portion of a cesspool or privy is within 50 feet ofy4 private water supply well.
X Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well"with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for-
coliform bacteria,volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:-
You must indicate either"Yes"or"No"as to each of the following:-
-
The following criteria apply to large systems in addition to the criteria:
The system serves a facility with a design flow of 10,000 gpd or greater(Large System)and the system is a significant threat to
public health and safety and the environment because one or more of the following conditions exist: t
Yes No
x the system is within 400 feet of a surface drinking water supply
x :the system is within 200 feet of a tributary to a surface drinking water supply
f
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area(IWPA)or a mapped Zone ill of a
public water supply well)
t
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 04J27)971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECLIST
Property Address: 104 Mitchel's Way Hyannis
Owner: Paula Phillips Bell
Date of Inspection:1111197
Check if the following have been done:YOU must indicate,either"Yes"or"No"as to each of the following:
,c_ _ Pumping information was requested of the owner,occupant,and Board of Health.
x None of the system components have been pumped for at least two weeks and the and the system has been receiving normal
flow rates during that period. Large volumes of water have not been Introduced Into the system recently or as part of this
inspection.
x As built plans have been obtained and examined. Note if they are not available with N/A.
x The.facility or dwelling was inspected for signs of sewage back-up
x — The system does not receive non-sanitary or industrial waste flow.
-c_ — The site was inspected for signs of breakout:
x All system components, excluding the Soil Absorption System, have been located on the site.
x The septic tank manholes were uncovered,opened, and the interior of the septic tank was inspected .
for condition of baffles or tees, material of construction, dimensions, depth of liquid,depth of sludge,depth of scum.
x The size and location of the Soil Absorption System on the site has been determined based on
— — The facility owner(and occupants, if different from owner)were provided with information on the proper maintenance of
Sub-Surface Disposal Systens.
x _ Existing information. EX.,Plan at B.O.H;
Determined in the field(if any failure criteria related to Part C is at issue,approximation of distance is
x {
— — unacceptable)[15.302(3)(b)]
(revised=7197)
SUBSURFACE.SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 104 Mitchers way Hyannis
Owner: Paula Phillips Bell ,
Date of Inspection:1111197
FLOW CONDITIONS
RESIDENTIAL: d/bedroom for S.A.S.
Design flow: 0 g'p' '
Number of bedrooms: 2
Number of current residents: 0
Garbage grinder(yes or no): No
Laundry connected to system(yes or no):No
Seasonal use(yes or no): No w,
Water meter readings,if available:(last two(2)year usage(gpd):
House has town and well water,well water to be used onlyfor outside watering of the property.
Sump Pump(yes or no): No
Last date of occupancy: nia '
COMMERCIAL/INDUSTRIAL:
Type of establishment: nia
Design flow:0 gallons/day
Grease trap present: (yes or no) No
Industrial Waste Holding Tank present:(yes or no) No
Non-sanitary waste discharged to the Title 5 system:(yes or no) No=
Water meter readings,if.available: We
Last date of occupancy: nta
OTHER:(Describe) nie
Last date of occupancy:
GENERAL INFORMATION-
PUMPING RECORDS and source of information:
rda
System pumped as part of inspection: (yes or no)No
If yes,volume pumped:0 gallons
Reason for pumping: Na
TYPE OF SYSTEM
Septic tank/distribution box/soil absorptions system
x Single cesspool.
x Overflow cesspool
Privy
Shared system(yes or no) ( if.yes,attach previous inspection records,if any)
'1/A Technology etc.Copy of up to date contract?. ,
Other:
AP
PROXIMATE AGE of all components,date Installed(if known)and source Information:
1950
Sewage odors detected when arriving at the site: (yes or no) No
(revised 0412719T) -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(contlnued)
Property Address: 104 Mitchers way Hyannis
Owner: Paula Phillips Bell
Date of Inspection:1111197
SEPTIC TANK:
(locate on site plan)
Depth below grade: rda ;, .. .,
Material of construction`.x concreate_metal_FRP_Polyethylene_other(explain)
If tank is metal, list age o Is age confirmed by Certificate of Compliance No (Yes/No)
Dimensions: rda
Sludge depth:ola
Distance from top of sludge to bottom of outlet tee or baffle: rda
Scum thickness:rda =
Distance from top of scum to top of outlet tee or baffle:rda
Distance form bottom of scum to bottom of outlet tee or,baffie:rda
How dimensions were determined: Mea:urea
Comments:
(recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
rda
GREASE TRAP
(locate on site plan)
Depth below grade: rda
Material of construction: _concrete_metal_FRP_Polyethylene_other(explain)
Dimensions rda
Scum thickness:rile
Distance from top of scum to top of outlet tee or baffle:rla
Distance from bottom of scum to bottom of outlet tee or baffle: ria
Date of last pumping,(. r
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid level in relation to outlet invert,structural integrity,
evidence of leakage, etc.)
rda
BUILDING SEWER:
(Locate on site plan)
Depth below grade: re^
Material of construction:_cast iron 40 PVC_other.(explain)
Distance from private water supply well or suction line?own
Diameter: 4"_
Qmments: (conditions of joints,venting,evidence of leakage,etc.)
(revised 04127)971
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 104 Mitchel's Way Hyannis
Owner: Paula Phillips Bell
Date of Inspection:1111197
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade: Na
Material of construction:_concrete_metal_FRP_Polyethylene_other(exp lain
)
Dimensions: We
Capacity: Na gallons
Design flow: ria gallons/day
Alarm level:_nfa Alarm in working order?_Yes_No
Date of previous pumping:
Comments: "
(condition of inlet tee,condition of alarm and float switches,'etc.)
Na .
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:'nia r d
Comments:
(note if level and distribution is equal, evidence of solids carryover,evidence:of leakage into or out of box etc.)
roa
PUMP CHAMBER:
(locate on site plan)
Pumps in working order.(yes or no)No
Alarms in working order(yes or no)_Y: t
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,etc.)
(revised 04127797) " ,
O '
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 104 Mitchel's Way Hyannis
Owner: Paula Phillips Bell r, ;
Date of Inspection:11(1197
SOIL ABSORPTION SYSTEM(SAS):x
(locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive methods)
If not determined to be present,explain:
nla
Type:
leaching pits,number: n18 #
leaching chambers,number:We
leaching galleries,number: nla
leaching trenches,number,length: rda
leaching fields,number,dimensions:nla
overflow cesspool,number:s'x5' Name of Technology: rda
Alternate system: nra —
Comments: (note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation, etc.)
ovsrnow cesspool Is Less than 50'to wetlands. -
CESSPOOLS:x
(locate on site plan)
Number and configuration: one
Depth-top of liquid to inlet invert: 8"
Depth of solids layer: V
Depth of scum Payer. V
Dimensions of cesspool
Materials of construction: block
Indication of groundwater: nla 7
inflow(cesspool must be pumped as part of inspection)
nta - t
Comments:(note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.)
cesspoos Is lose than 5o•to wetlands,
PRIVY: «
(locate on site plan)
ions: ,
Materials of construction: n1a Dimensn1a i
Depth of solids: Na
Comments: (note condition of soil,signs of hydraulic failure,`level of ponding,condition of vegetation, etc.)
rVa
y
(revised 04127197)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
104 Mitchel's Way Hyannis
Paula Phillips sell
1111197
SKETCH OF SEWAGE DISPOSAL SYSTEM: Y
include ties to at least two permanent references,landmarks or benchmarks
locate all wells within 100'(Locate where public water supply comes into house)
. O C
AA�� (3
OR jo
O
TC
(revised04R7197) - page 9 of 10
r
e �
SUBSURFACE'SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
104 Mitchel's Way Hyannis
Paula Phillips Bell
iiNf97
Depth of groundwater 10
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from design plans on record.
Observation of Site(Abutting property,observation hole,basement sump etc.)
Determine it from local conditions
Check with local Board of Health
Check FEMA Maps
Check pumping records
Check local excavators, installers
X Use USGS Data -
Describe in your own words how you established the High Groundwater Elevation.(MUST be completed)
USGS Maps and Charts
2
(revised04)17197) ]page 10 of 19
I
TOWN OF BARNSTABLE
CATION )()F h);Jr.kejle'f A SEWAGE #
Vt LAG E r,bil ASSESSOR'S MAP & LOT .
INSTALLER'S NAME & PHONE NO.
SEPTIC TANK CAPACITY J,QaQ Cal
LEACHING FACILITY:(type (size) l
NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER
FOR OWNER �(a,Y'n�r
DATE PERMIT ISSUED: '
DATE COMPLIANCE ISSUED_=[G��'�--
VARIANCE-GRANTED: Yes No I'�
>+� -
O
-1�� �i�;b. z� 91 -.
� � � / X
I/ / ,: � 1
.� �.� � i
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k
ra��
i
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— _-
'r
THE COMMONWEALTH OF MASSACHUSETTS
BOARD , OF HEALTH
TOWN OF YARMOUTH
Appliration for Disposal Murky Tonstrnrti -
Application is hereby made for a Permit to Construct ( ) or Repair X an Individual Sewage Dispo
sys�m at: -
lOtS Mitchells Way Hyannis
-----------------------_..........................................................._........... _..._..-----••--•-------..........---........_..--••----..._...------•-•......_...---....._------
Turner Location-Address or Lot No.
..............__ .......................................................... -----..._....--•--•-•---•--------•-------•---••------•------•--------...---------.................
Owner Address
W J:P:Macomber Jr. ....................••••••---••-----•-
pq Installer Address
d Type of Building Size Lot............................Sq. feet
aDwellingXY,No. of Bedrooms...........................................:Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building_____________________________ No, of persons............................ Showers ( ) — Cafeteria ( )
QOther fixtures ----------------------------•-------._......-•-----•--.-----......_*-------------------------------•...._..--•---•--•----._..._•---------•------......
W Design.Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid'capacity________....gallons Length................ Width................ Diameter................ Depth_____._____-_--.
x Disposal Trench—No..................... Width......:.............. Total Length.................... Total leaching area...................sq. ft.
3 Seepage Pit No..................... Diameter...._............... Depth below inlet:................... Total leaching area..................sq: ft.
Z Other Distribution box ( ) Dosing tank ( )
1.4 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........................
9 ---------------------------------------------------•--.... .........
---•-••------------------
----------•----- ------------
•-••........
-...............
O Description of Soil----•-•--•---•----••----•-••-------=--•SaYltl.. ..- ire 1 ....................•--.....--•--•---•--------....--•---..._.. .
^�
W -------------•---•--_---------------------------------
__------------------------------
•----------
•---
•---------
•---------
------------
-----------------------------
•--------
•------
-•----____-----
..--•••-------------------------------------------------------------------------------------------------------
V Qapplicable -.inlan £ank••-1-1�00 --------------
Na uj oReTirsqr aching
—Answer when -----------•--------------�•---------------••----•------------..__...._....-----•--......._..
P
..............•------........--•-----•-•--...----...._........----------•---....._._....----:....-------•-------•--•-•---.-.-----•------------•---•-----•-----------------..._...._......._....._••-_...
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of iITi M 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has bee issued y tl}�e board of heal
Signed /'/ flC�/� ' -••--••------------- 4ll3Y.92......_....
Date
Application Approved By.............. �^Z ..... ---•------•---•-- _-I--3.:...?.
Date
Application Disapproved for the f o owing reasons:----•-••-------•-•--•--•------••--•-------------•---•--------....:-.-----------...-----------•-••-•-••------_...
Date
Permit No........ Issued_....................
Date
'�"'�pr�'� ,"'�"�'6`��+•�7,,�4'�«filt�Cty(}�''� � f� r� .. fii���lT-��- � �`��i�t ��`-7 7'`•""1.�'t�f`3�"'/J'*d�"
Awl
ty
No_.. r.. /. 6 Fzcs.30 00
E. _. .
THE COMMONWEALTH OF..MASSACH.USETTS
Y BOARD OF-!'HtEALTH
TOWN OF YARMOUTHrLj
Appl ration for Disposal Works Tonstrixttion
Application is hereby made for a Permit to Construct ( ) or Repair �1�1 , an Individual Sewage Disposal
Sy at:
10) Mitchells Way Hyannis
------------....««««..._................._...__........................._........«......R... _................_..._._._..............._•--_-----_--.._.._............_.....«..................
Location-Address or Lot No.
Turner
....- ._... «..««__.......
«......
-------•--•---..•..-•-----------
----------------------- ••----------------
... ..........:...............................................«___.....
Owner Address
J.P Macomber .................•••••-•...... ....................._........._.................. •--••••--••••-••----•-••.._.._.........•••.
.............. .....-• Jr.J........_............_.._..
Installer Address
Type of Buil� Size Lot................ .. Sq:`,feet
--------- -
a Dwelli No. of Bedrooms.........._.................................Expansion Attic ( ) .Garbage Grinder ( )
pa Other—Type of Building`---•••---•------------------ No. of persons..............._...._...._.. Showers ( ) — Cafeteria'' ( )
A' Other fixtures ................ k
W Design Flow.....-•.....................................gallons per person per day. Total daily flow..............•...._...._........._.:.......gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Widths,.............. Diameter................ Depth...ei...........
x Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
3 Seepage Pit No...................... Diameter.................... Depth below inlet_._.................. Total leaching area..................sq. ft.
Z Other Distribution box ( ) - Dosing tank (, )
Percolation Test Results Performed by -------------------------------•--------------...................... Date....._.___........._._._a...............
Test Pit No. I................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........................
0 ai .•-••-•••--••••---••---•-••--••-••....••---••-•-.....-••-•-••••••...........:................................................................................
Description of Soil....................: .--------------•SE d...&---Gf0 e1---------
W ............................................................................•---•---...---------••-----•-•--------..�. .....---•-•.............•-•••-•-••-.........-•••-•----•-•............••..•-
.. ••--------- 1-__ JOJ----••-•1i•---•----t--.--.k...1..10J�_...••...........
Natu of Re airs r terati s—Answer when applicable...........................tea Ori ari —
v gaielon each ................................................................................................................................................................
Agreement-,-
The undersigned,agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State.Sanitary Code— The undersigned further agrees not to place the system,in
operation until'a Certificate of Compliance has been issueay board of health.
+.. .-
a..- Signed. . .�
••--- , Vi3/.()2...........
Date
Application- Approved BY•=•-• ......... ...•••. •.•. •_ -------- --- •. `i.------• ......
Application Disapproved for the`fo, owing reasons: ............................................... Date .«
-•-••-•-------•--•--•---......--•---.........-/•..........................•r-'•.-------------...................-----.....----------------------------....-----------•---.....-------•-•-.... ---•---
• t '.. ..'_. -••- .......................Permit No.---•- 3"; Issu
µ .. Date
s
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH "w=,
TOWN of YARMOUTH
Trrtifiratr of Tomplianu
THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired �X)
by.......J___—-- ..Macomber Jr..............................................................................................................................................
108 Mitehells Way Hyannis Installer
at..................•-••...•-••...............•••.........----••••... ............_..••-••--•....--------------•-•-............----•-...............-•----.........---------•-•-•..........._.....
has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit No--------Y L/1 -.... dated................................................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
._ DATE.. 1. +� Inspector--•• -- ---- ----.. .._ ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD . OF HEALTH
TOWN of YARMOUTH
No... ��1..! F$E........�...00
Disposall9orks Tonotrudion ramit
Permission is hereby granted....J,-p Ma C Omb e r J r.
.................. ........ .
«....
to Construc ( ) or Re
it)( a Individ al Sewage Disposal System .
at No.._-19�_Mitche �s ��y nfi._....y.ann. .....s..
................. ... ......... ...._.............- ........... ......
Street
as shown on the application for Disposal Works Construction Permit No.,,?c2.-S..'./ . Dated.!.......................................
DATE. .. _ .... .�............................ Board of Hcalth
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TOTAL- E• ST/MfgTED F4- LV/TAJ E5SEC-) f3Y .
/ I "�•ia,� ��;� ! y �., (--IL2 GAL./8)2./DP-r- X e3f�? : PERCOLATION )e-/9TE `' M/R///tiJGH /
{ . �` ,1 r �•/� \\ G,9L.�DFIY ✓ � _. , f ,�/ ' _ ;�^• is !
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