HomeMy WebLinkAbout0112 OCEAN DRIVE - Health 112 Ocean Drive
Hyannis
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is � d yi yi I S MA 02672 0428/13
required for every
page. City/Town 2Cp6 _O('ej State Zip Code Date of Inspection
=; Inspection results must be submitted on this form.Inspection forms may not be altered in any
way.Please see completeness checklist at the end of the form.
Important:When A. General Information
filling out forms
on the computer,
use only the tab 1. Inspector.
key to move your (�
cursor-do not Michael Kellett
use the return Name of Inspector
key.
Aardvark Environmental Inspections
—V Company Name
PO Box 896
Company Address
East Dennis MA 02641
City/rown State Zip Code
508-385-7608 SI 3742
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 otgn sita,
sewage disposal systems. I am a DEP approved system inspector pursuant to tion 15: 0 ofa
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Failg)
03
❑ Needs Further Evaluation by the Local Approving Authority
05/01/13
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority (Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP.The original should be sent to the system owner
and copies sent to the buyer,if applicable,and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•11110 Title 5 Official bsurface Sewage Disp/1�osal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is West H annis rt
required for every Y Po MA 02672 0428/13
page. City Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary:Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired.The system,upon completion of the replacement or repair,as approved by
the Board of Health,will pass.
Check the box for"yes","no"or"not determined"(Y,N, ND)for the following statements.If"not
determined,"please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
r
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•11/10 Ttte 5Offcial Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
"s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is required for every West Hy �annis rt MA 02672 04/28/13
page. Citylrown State Zip Code Date of Inspection
B. Certification (cunt.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)thatthe system is not functioning in a mannerwhich will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
6"1n3•1 IS IC --a J VIIGICI 111�lCWYII Fwm.aubsuiftce JGWGae VSpomI JY-steT•Page'.al 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive_
Property Address
William Winslow
Owner Owner's Name
information is required for every West Hyannisport MA 02672 0428/13
page. Cityrrown 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:
[] The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a.DEP certified I bo y pa ys , plaboratory,for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6"below invert or available volume is less
than day flow
t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
IBM Title 5 Official Inspection Fora"
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is required for every West Hy �annis rt MA 02672 04/28/13
page. Cityfrown State Zip Code Date of Inspection
B. Certification (cunt.)
Yes No
❑ 0 Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis,performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303,therefore the system fails.The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems,you must indicate either"yes"or"no"to each of the following,in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes"in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304.The system owner should contact the appropriate
regional office of the Department.
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
= v. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments
a 112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is required for every West Hyannisport MA 02672 04/28/13
page. C4/'rown state Zip Code Date of Inspection
C. Checklist
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner,occupant,or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components,excluding the SAS,located on site?
® ❑ Were the septic tank manholes uncovered,opened,and the interior of the tank
inspected for the condition of the baffles or tees,material of construction,
dimensions,depth of liquid,depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the maintenance of subsurface sewage disposal systems?
proper 9 P Y
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
® ❑ Determined in the field (If any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins•11/10 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is required for every West Hy �annis rt MA 02672 0428/13
page. Citylrown state Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 0
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?[f yes separate inspection required] ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ® No
Water meter readings,if available(last 2 years usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 10/10
Date
CommercialAndustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15203):
Gallons per day(9Pd)
Basis of design flow(seats/persons/sq.ft.,etc):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings,if available:
t5ins 11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
x '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is required for every West Hy �annis rt MA 02672 04/28/13
page. City/Town state Zip Code Date of Inspection
D. System Information (cunt.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes,volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank,distribution box,soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system(yes or no) (f 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 VA system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•11/10 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Forth-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is required for every West Hy �annis rt MA 02672 0428/13
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components,date installed(if known)and source of information:
25 Years
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
feet
Material of construction:
❑cast iron ®40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints,venting,evidence of leakage,etc.):
Septic Tank(locate on site plan):
Depth below grade: 0.7
feet
Material of construction:
® concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain)
If tank is metal,list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1,500 gal
Sludge depth:
2"
t5ins•11/10 Title 6 Official inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
formation is West Hyannisport MA 02672 04/28/13
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cunt.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
29"
Scum thickness
1"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
16"
How were dimensions determined? measured
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
The tank was sound and tight with tees in place and liquid at outlet invert
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•11/10 Trlle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is required for every 04 West Hyannisport MA 02672 28/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,
liquid levels as related to outlet invert,evidence of leakage,etc.):
Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal ❑fiberglass ❑polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm•level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches,etc):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•11/10 Title 5 official Inspection Form:Subsuirace Sewage Disposal System-Page 11 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�l 112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is required for every West Hy �annis rt MA 02672 0428/13
page. Cityrrown state Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(d present must be opened)(locate on site plan):
Depth of liquid level above outlet invert even
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any
evidence of leakage into or out of box,etc.):
The box was level and tight with no sign of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
Soil Absorption System(SAS) (locate on site plan,excavation not required):
If SAS not located,explain why:
t5ins-11/10 Fide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 '
Commonwealth of Massachusetts
Title 5 Official Inspection Form
"s subsurface Sewage Disposal system Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is required for every West Hy annisport MA 02672 0428/13
page. Citylrown state Zip Code Date of Inspection
D. System Information (cunt.)
Type:
❑ leaching pits number:
® leaching chambers number: 4
❑ leaching galleries number.
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number.
❑ innovative/aftemative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of
vegetation,etc.):
This system has a 4 infiltrators in an 1 1'x25'field of stone.There was no sign of ponding or failure in
the stones.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•11/10 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
112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is required for every West Hyannisport MA 02672 0428/13
page. City1rown state Zip Code Date of Inspection
D. System Information (cunt.)
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,
etc.):
t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is required for every West Hy �annis rt MA 02672 0428/13
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system,including ties to
at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet. Locate
where public water supply enters the building.Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
rear
16 16 14
24
El
t5ins•11/10 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is required for every 42 West Hyannisport MA 02672 08/13
page. City/town State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
Estimated depth to high ground water. 7.1
feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators,installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
I augered to 8.0 feet and found no water.
I adjusted to 7.3 feet.
Bottom of leaching is at 3.7 feet
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17
Commonwealth of Massachusetts
lugTitle 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winslow
Owner Owner's Name
information is West H annis rt MA 02672 0428/13
required for every y �
page. Cityrrown state Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary:A, B, C,D,or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-11/10 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
do
` Commonwealth of Massachusetts
Title 5 Official Inspection Form
p o
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winsloe
Owner Owner's Name
inormation is West H annis
requiredforevery es Y port MA 02672 11/11/10
page. CityrFown State Zip Code Date of Inspection
Inspection results must be submitted n ed o this form. Inspection forms may not be altered p p t red in any
Y
way. Please see completeness checklist at the end of the form.
Important:When filling out forms A. General Information
/)
on the computer,
use only the tab 1. Inspector:
key to move your
cursor-do not Michael Kellett '
use the return key. Name of Inspector
Aardvark Environmental Inspections
�y Company Name
P.O. Box 896
Company Address
East Dennis MA 02641 `
City1rown State Zip Code
508-385-7608 SI 3742
Telephone Number License Number ;
B. Certification
i . I certify that I have personally inspected the sewage disposal system at this address and that the '
r 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
w� sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
f ; Z. Passes ❑ Conditionally Passes ❑ Fails
F"*
❑k Needs Further Evaluation by the Local Approving Authority
11/11/10
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
� I
f
t
Commonwealth of Massachusetts
tam Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winsloe
Owner Owner's Name
information is p required for every West Hyannis port MA 02672 11/11/10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® I have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
4
t
r
{
t.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
1
"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):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winsloe
Owner Owner's Name
information is West Hyannis port MA 02672 11/11/10
required for every p
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
5
4
1
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
l
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winsloe
Owner Owner's Name
information is West H annis
required for every Y port MA 02672 11/11/10
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory,'for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be'
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes" No
® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ , ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
lot, ^
CO-mr-n-Onliweal"M
A= &=iA_ff_Oz
1^rn a ire ii, P%L a vwirM mft
9i g I "",Vu �iO W1,1113 1=2 IS Z .-,
s NoL for-Vo--inta-,Ass-ssrn e t
ris
Isubsurface Se-fag--Disposal Sism-im For.m.-
iL .j t LA
Property Address
nwni,ir
is IAtI RAA nnczn 4 4 14 A 14^
'I remiff-PH mwpv�,Fv !V
Ect of i
B. Certification (conci
... ... 1!,1! A Ell IIU 1.111-1,
El Z
CI A Q -------I ---- ------ L__
Ain-a n o on ofthe D, ut�z�_-Ijuu! u! pnvvy I-- uz-vYY 1!!Y!!Y!vw1u. wcum.
nn 1 rir ri r: zi
im j L., vy
01
U U)UU_41 V 11)a!t�W IdLAUlinVULuif Z�UULAV.
7_1 - -------i -
Cd.1 9 v v I I I H I U"U, U L;i ia i,
Q Q i --VV6
I)I'V
U, ca dW IV LU ziuUtii- vuH.
F-I
_nw nn-tirm,rif n nri-aw :;z 1r_c:c;'Inn fimim� nn z_
1!I�t w VU,
Q�I u I a -�Fvu;
IT �x tM.
LN, WUNI VVILil NU 'WaLU UU-d-M dH&!VZflZi.
c-vetom passes if the well water analysis, performed at a DEP certified
110--al CO.Ifform. I)aczcrlz Malcal.eS,30SOM,--A esa�" -------
-m-Man M MITYM-Um. mrin artin-2,1P munn-An az Amin!tan.cir LAAA fuh2t". Sa rm-m-
-.1—M U
...... .....
F—I
f 17,
For la`r ge syslems, VOU MU stn' iicate either"yes"or"no"to each of the follming, in addition to the
El
F-I
Li F11
if unn F_lrp vJA,-r_;I qigatfi"i ;n Re finn 1-hr-QVQfArn
za.
Siystern in accordance with 31 C'C'MIR 15.304. The system ovvnar shO.Rjald tuhle app;,001 1�_
Commonwealth of Maasachuaeit
■r!!alst a ■_
I �c �e 5 UMCIall inspection 'Fol�i
Lubsuf-ce Ve.agpe Disposal System. For:::-Not for Voluntary A5sessme lts
iI LVicoiie, l Ljly
Propert;'Address
iAruinm 9Atinclne
Owner Owner's Name
information is
required for every West Hvannisport MIA 02672 I I/I i/inv
vay`e. City!?own State Zip Coie Date of inspection
Checklist
k,heyk if the following have been done. You must indicate"yes"or"no'as to each of the lol owing,
Yes Kin
1 uelloing in.orlieasiU'II was providedub the vei/el1er. oi,Cuuail., or Board of 1 ecals:t
Were anv,'1t the ayasclll COrnpol:cnts pull:i.,,ed out in the a,revivua sv'V`s) 1rY2c^ka:
❑ Has the system received normal flows in tie previous two week period?
❑ Have large volumes of water been introduced to the system recently or as part of
this inspection?
F71 Were as built plans of the system obtained and examined? (if they were not
Inj ❑ available note as l{eiA!
Wasthe fnn;l'+t r.r r7se.�il'nrr ' n fnr n r.n i�enr.4 7
dtl QJ the Iees,Ilisd vI ure et:itl� iil�p�'ct2d Ivl signs of srevdaue Si F% is°12:
Z El Was ias the sit inspected 101 sians of beak out -
0 ❑ A/ n it - #.� nn ^ +n ,ling'-he C located --situ?i
v`c'rc all sysscrn t+Vmpo:IGnLJ� cxi,luulll�p s vAS, w�,at`ed vtI
a a--1-
® El Were the septic tank manholes uncovered, opened; and the lnterlol. =1t1 Sl rk' !�!+!<
inslected for ti ie eoi lu ion of tiI uaffies or tees. mate�ateI ia11 isf i3O nate t.ieiiii:.
(IJ9men7,n9l6 drama rif lininil fiepw-—if--hudnr;;nil fi=irt a tri czri1-0
- - -�T--; - I -- ,_ -- - -
❑ Was the facility owner(and occupants if different from owner, prodded with
u nor mativn the P +nnan- e rsf ,�nns-_ag rF'nn--i - ---
on LI:c urt'r,�c, limns Iraltvc vI auDssufface s e-a=.e ui�usJ�cf: ,ti�itiii v�
.._.___sib; nA :_-_- _ =f: `--=_==o= So"Al s--Pl_--
K71 r.,: a:=_ :_e__ a: r___ t 1 _ a at.- n ._e c t t taL
—a-sting,g, 1nivinicitio11_ FJl exampIC, a plait Gt the �UL�".d Vl 1-1CL�1L'.1.
-- -z
v nr.i!-. :- -
{L�! ❑ �vcv.3: :[tee� N rl (;[Tm qtl -s'�.-- �l
ati�vls.fxaiiiU d Jt Cti9U:ii LL: Is UNdL;_�: aEii; i.J{li'vii%iti �.,3 c •ii
Residential Flow Conditions:
s`' : ririls,i Etf ra (szly fe=ditsl ' 6-€ i-inpr`• `P r ie',r . 3:f`i3y3s'
r i u 1 n n ng a m � , awn [bedrooms):
DESIGN flow baser on 31 V C,'MR 1 a.203 (for example. I I iJ gpd x##of bedrooms):
d '
' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System !Fonda e Not for Voluntary Assessments
i 12 vCean ur Jve
Property Address
1Afilli�en 9f\dinc!nc
LI
Owner Game;s"a Me
info i oboe is every West Hyannisport MA 02672 11t11/1Q
page. Ci y Town State Zip Code Date of i^sPection
D. System Information
Description:
Number of current resiue,^,ts:
i�! n Imusi n. !� n hr hr7 El `inn -
dJV�J 1GJiden�e have a garUayj yiiiidci i es No
Is iauiidry vii a��vvJB aiatrc'sewage syst2iid. t!irif yus$c(`iaratc F3 lnJc�tivii required lea
Lauiidi V syste l l inspected? ❑ Yes Z, No
Seasonal use? ❑ Yes M No
Water meter readings, if available(last 2 years usage(gpd))-
Detail:
Sump pump? ❑ vies Z No
ne.fr..�t
Last date of occupancy: e,is
Date
C.A,d:d.".6e€cia€ilindddStria flow IConclit-ions:
Type of EstaUiisi ent:
Design flow(paseo on 310 C-MR i 5-203):
Gal ions per day(gpd;
Basis of resign flow(seats/persons/sq.1t., etc.).
Grease trap Jresent. El Yes ❑ No
Industr iail waste hoidin"q taiink ,rnco,eni? ❑ 'f cs ❑ Nv
`Inn n d^� }h S } 'k^ fl } , '? In
lVvi 1, al y rva�te discharged gcu LC ties T it!e 1d SSjatei I I �i eS e�ev
Water meter readings, if available:
Commonwealth of iviassachusetts
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Uip.,
Property Address
William Winsloe
Owner Owner's Name
information is
required for every West Hyannisport MA 02672 11/11/10
page. Cityiii own State Zip Code Date of inspection
D. System information (--onL_)
Last date of occupancy/use: Date
isterer(describe below):
Genera: information
Pumping Records:
Source of information:
Was system, Dumped as pat of ILh
L a inspaCiiL�ii i: ❑ Yes, i�^^
If yes, volume pumped:
gallons
How was quantity purnpe�ld deter mined?
Reason for pumping:
i ype of System):
Septic tanrt, distribution box, soil abSor ption system
❑ mingle cesspool
❑ Overflow cesspool
❑ Privy
❑ 'hared 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 UA systemI by SystermI operator under contract
❑ Tiyh:tan�. At4ac I a copy of the L.,=P approval.
Other(describe'-:
r
• .�,;� c��_���_�-_---- _- ��s�-------==�=ter
Will
i1,tita
_ 2672
D. System
tm in from tion (cont.)
i>...a N :at.
Building Sewer r 11- t4Y on sit,
r plan):
Ia- 1.
calk law,god,
tl Merin!cf c=ntructe^n•
4
irT
L:dSL ii Uil - - V"i 4 PVC uiiici
•i=4e±'3:r, from -_ b F3m '._ Mr- - - o:te4 well i3i lea ii iI `ii -,
L:nmmAntR Inn rnnrntinn nT mints VP_nilnn P_vinP.nrP nt IAaKaae P,Tr 1'
tiP_nTir B ank I In(.ATP.on sITP !)I;;n
Depih beicw grade:
n�
Materia!of nonstn Intion•
LN UUIIUIULU ^ IIICld1 ... I--,
i _ i___i � IIUCIL,iIi:IJS Li [JUIyCUlylellC Li�ULfICI iCRuldltll
14 4nnli .n mri4^I I�n4.n^^•
years
19 aye confiff ied by a Cei tiricate of Compliance! (attach a copy of ceiTiTicate) U Yes E] o
Dimensions; 1600 ga!
Sludge depth:
f
Commonwealth of Massachusetts
�i�i� v is hl Inspection ection F®�"I�i'i
Subsurface Sewage Disposal System Forge-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winsloe
Owner Owner's Name
information is required for every West HyannisDort MA 02672 111,11f10
page. City,i own state Zip Code Cate of inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle 29,:
Scum thickness 2:
i A ance korsi top of scorn to top of routie Cts+e- or hafflo
6"
i v
Distance f bottom
scum to bottom of i tlet to r baffle Vi��aiiuv Toni e3ottoil:of SCt, 0..i :.�,:;, ,..aic'sc
- - - -L.. _ measured
::E; � were dim en iC isit111.ss. dete i i iii iC:J! -
- e - um._ coi;Y leer tion� �._d outlet eel r baffle a _tnuct.. nt g it..
e._:e �ic1.. r:f<:ice..:� ��.`+. ...._ ----r__---_- ____-_-_ __.-�..,�-y -�-�.--_ --__-___- � -__r_.- -_ --_' .� J
liquid levels as re1:4iCr.9 e`,-_+,1..:'„E;.icy+i ii:ve -_.d ee:,-.— .:,_.tar eta-, e
Ejr� ice: r� _:_-__..'_-....
_ :___ _} : _ �€ a :.h_:�:u__
Scum`= -4:;rubs
Eisur_,_€l-om t,rifriY'i of scL9fi'l'to brsttotn of outlet tee or baffle
�a� r e e_ a-e-
o-*3nt�t5:rtwealth �: IyBs�ad�'�C3�9!l�a�BEa
Ta�ae 5 0 lanais In,pcCL®�s 1
Subsurface Sewage Disposal System Form -blot for Voluntary Assessments
112 Ocean Drive
Proner:v Add(ess
lAhiiiam lid�r S9t7e
Owner Owner's Marne
_ee _T_
(€"UtJ€(et�f for every
_ - �
page. @CiitylTawn State Zip Code Cate of inspection
Comments(on pumping recommendations, inlet and outiet tee or baffle condition, structural integrity,
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Denfln oelov:,trade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ ether(explain).
Dimensions:
Capacity:
gallons
Design, GIo.%,:
gallons per day ,
Alarm present-. ❑ Yes ❑ do
Aiarm level: Alarm in working order: ❑ Yes ❑ No
Date Of,ifs_,'.l iwmpaf i I'1wi..
Comments (condition of alarm and float switches, etc.):
. I
Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No
Commonwealth of i�ia�sact�f��e�s
Title %5Officeae 1e Ispect➢®n Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
yyiiii_iii 3:
Owners
Owner wner s Name
information is required for every Y West 16 annisport MA 02672 11/11/10
page. City,—,own State Zip Code Date of inspection
De System 19e1orma—tion "cont.'
nkt rihiifinn RnY (if nrpGpnt mi mt'P. i)nP.nP.,1 e i ini_qtp i ii i GitR i tiA i,-
.Mpiii of Hquiv level 2b-ove outlet invert
LEven
n".li i fip tt :aiY it i'ei tz m ii-vr, ani, i ii-ctrini itii i i ti i rii itiiri r--iii i:ei ;;ry in-virSFnrr-i—,Gi iiitSC r-Ar r vrivr-r Any
U. U-.i:a,bs€...viiii7v. _LjiiMsiy:=•..s Uii:3iy4*-.>;-u ois q+s+s dca�,:i
Commonwealth of Massachusetts
I ILIA v %0111 ��i �S i� ��`ivl'i1i' �oi"i7e
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winclna
Owner Owner's Namev
information is p
recurad for eEery �West H annis ort MA 02672 11/11/10
page. City,—,own State Zip Code Cate of Inspection
D. System information (coat.)
Type:
❑ leaching pits number:
® ieachinq chambers number:
❑ ieachinq galleries number:
❑ ieachinq trenches number, length:
❑ leaching fields number, dimensions.-
overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
This system has 4 infiltrators in an 11'x_25'field of stone. There was no sign of ponding or failure in
the stones.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow El Yes ❑ No
iommonwealm" of it"Iassachuse s
Title 5 OffiCiai 9nspectio I INJrIII
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winsioe
Owner Owner's Name
information is �required for every �West H annis ort MA 02672 11/11/10
page. City/Town State Zip Code Date of Inspection
D. System information (cunt.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winsloe
Owner Owner's Name
information is West Hyannisport MA 02672 11/11/10
required for every State Zip Code Data of Inspedion
Me CRyfrown
D. System Information (cont.)
Sketch Of Sewage Disposal System:Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
Q49-f
i
Commonwealth of Massachusetts
TOLSC 5- Offkc;iall Iinspectiore i C®i I l i
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
112 Ocean Drive
Property Address
William Winsioe
Owner Owner's Name
information is West Hyannis port MA 02672 11/11/10
required for every p
page. Cityrrown state Zip Code Date of inspection
D. System information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallow wells
1 6.1
Estimated depth to high ground water: feet
Please indicate all methods used to determine the high ground water elevation: ti
❑ Obtained from system design plans on record
If checked, date of design plan reviewed: Date
Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-expiain:
❑ - Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-expiain:
You must describe how you established the high ground water elevation:
1 augered to 8-0 feet and found no water.
ladjusted to 6.1 feet.
Bottom of leaching is at 3.7 feet.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
l}1IGH GROUND-WATER LEVEL COMPUTATION
Date:
Permit:
Site Location:
Phone:
owner:
Phone: °
Contractor:
Notes:
STEP 1 Measure depth to water table `1 0
to nearest 1/10 ft. Date: << �� J V
(depth is in feet below land surface) mm/dd yy feet below is
STEP 2 Using Water-Level Range Zone and Index Well `
Map locate site and determine: '
MWO
A) Appropriate index well
B) Waterlevel range zone
Using monthly "Current Water Resources
STEP 3
Conditions" determine current depth to water
level for index well.
mm/YY ,
STEP 4 Using Table of Potential Water Level Rise for
index well (STEP 2A), current depth to water
level for index well (STEP 3), and water-level
zone(STEP 2B) determine water-level Ell
adjustment.
MPS water b subtracting the b 0
Estimate depth to high Y
water-level adjustment(STEP 4)from
measured depth to water level at site (STEP 1).
to this file.
MOTE* Ta tiles 1-9 "Potential Wlater-Level R[sea are attached as worksheets A
,
i
monthly index well data: ww"-capewdcor»miss►on.org/wells.html
TOWIN OF B S �S-LkBLE
OCATION TaH4/`4--..— SEWAGE # M
�✓tLLAGEy� ii`�`S` n 6 ASSESSOR'S MAP & LOT Z 6(f 0 �G
INSTALLER'S NAME&PHONE NO. Z22/,6 Cif 12--P..
SEl'i11C TANK CAPACITY ,
i.EACHING FACILITY: (type) ,��-�-8 72i4-f (size) 4�.—�� .
NO.OF BEDROOMS -
B WILDER ORS VNER 1 CAi t
PERMITDATE: �U " �5'9 COMPLIANCE DATE- ll—1 -7
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist -
within 300 feet of leaching fa ility) Feet
Furnished by '4�
r
.,a
t
C:
I
c
y
i
No. Q < Fee
THE COMMONWEALTH OF MASSACHUSETTS
Entered in computer: ✓
Yes
PUBLIC ALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for rigpogar *pgtem Congtruction permit
Application for a Permit to Construct( )Repair( )Upgrade( )Abandon( ) Si5complete System ❑Individual Components
Location Address or Lot No.��a Q r �t� Owner's Name,Address and Tel.No.
�`�"'```SR'� tJlJ1Q�s`8�.�
Assessor's Map/Parcel ,)�6,• oppr
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
\5 L 0,A s 5t,
Type of Building:
Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixture�s-2
Design Flow gallons per day. Calculated daily flow 3"� gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank Crb Type of S.A.S. A cI7T
Description of Soil y Vim-cS
Nature of Repairs or Alterations(Answer when applicable Sra �� n` � 6 cawc ~
PP
Cr—V T_. . ,
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has
Signed Date AO '
Application Approved by Date ®— Zj
Application Disapproved for the following reasons
Permit No. 7 0 c/ Date Issued 0 r
.-•-'/` r� 3..a`
No. � 70 � tT'v ,. _. _ Fee
v
r THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: ll
Yes
PUBLIC HE"ALTH DIVISION -TOWN OF BARNSTABLES MASSACHUSETTS
application for ;Digpoal *pgtem Construction Permit
Application for a Permit to Construct( )Repair( )`Upgrade( •:::)Abandon( ) omplete System ❑Individual Components
Location Address or Lot No. l!cam)—Oa� Owner's Name,Address and Tel.No.
_ Assesspr,,'s Map[Parcel, �.�� 0 08�
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
(kl 6—c t a (-t
�J 10,i1S 5T< r'/ ����Cj
Type of Building: f
Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixturess-7.7 Design Flow 3(D gallons per day. Calculated daily flow _—3'kc1 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank (fb Type of S.A.S. jlc V\,C /k c,
Description of Soil y y` S)q(�,_Z- {�
Nature of Repairs or Alterations(Answer when applicable) T-r �tp �1 / 4`�. n,`�
��H,C_k. t� , ___c'C�_ =cL.L_oL�yc.�o�(j.5
Gc-r4'r�,. tl� �
Date last inspected:
Agreement: j
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system Asf
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has by ar o a _ A
Signed Date
Application Approved by _ Date Z)
Application Disapproved for the following reasons ¢
Permit No. �' 7 0 c/ Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of Compliance
THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed�;(� O�Repair�d�( )Upgraded((�
Abandoned( )by A', —C to ilo .5•e[2l`C �'f
at = t` C �N �f-G2 UJe.S�C 1�wC,u�-+t`c S 1 Q\ has been castructed in accordance
with the provisions of Title 5 and the for Disposal System Construction Permit No. —7 U '-dated /d"Z S— 9
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the sys a will func=ns• sig d.
Date it_ Z-9l q Inspector
No.— -- -- ------------------------- ---
_--
70q
Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
F
'Wi5po5al *pgtem Congtruction Permit
Permission is hereby granted to Construct( )Repair( )U grade Q OjAbandon( )
System located at - vt/
cc� _ a
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
be completed within three years of the date of this e t.
Date: �d!2 s r�( Approved by
1/6199
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only. -
CERTIFICATION OF SKETCH AND APPLICATION FOR A DISPOSAL
WORKS CONSTRUCTION PERMIT (WITHOUT DESIGNED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated concerning the
property located at //v� O C6iU meets all of the
following criteria:
/The failed system is connected to a residential dwelling only. There are no commercial or business
uses associated with the dwelling.
The soil is classified as CLASS I and the percolation rate is less than or equal to 5 minutes per inch.
There are no wetlands within 100 feet of the proposed septic system
There are no private wells within 150 feet of the proposed septic system
-There is no increase in flow and/or change in use proposed
There are no variances requested or needed.
The bottom of the proposed leaching facility will not be located less than five feet above the
ma.�dmum adjusted groundwater table elevation. [Adjust the groundwater table using the Frimptor
method when applicable]
1/ • . If the S.A.S. will be located with 250 feet of any vegetated wetlands, the bottom of the proposed
leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation,
Please complete the following: g
A) Top of Ground Surface Elevation(using GIS information)
B) G.W.Elevation �I +the MAX. High G.W. Adjustment A
DIFFERENCE BETWEEN A and B l 'J
SIGNED�: � DATE:
[Sketch proposed plan of system on back].
q:health folder.cert
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General Notes:
1.All work to be performed in accordance with Massachusetts State l3ttilding Code,180 CMR,
Eighth L'dition,IBC 1009,and applicable codes included by rcfereitce.Frvrning to be in -...
accordance with the American Wood Council Wood Frame Constrtction Manual.110 MPH
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Zone.All work to be ac approved or directed by local authorities havingjurisdiction. --_
2.Contractor to secure all permits,and to arrange for inspections by local authorities having
.. jurisdiction,as mny bz required. •
3.Work to he left in clean condition,ready for use and occupancy.'All debris to be disposed of[
site in a legal mtmner,
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4.Contractor to install plumbing,electrical,heating and venting c}5[ems as required_per code. i• -
_ Install new smoke and carbon monoxide detectors,per code. {-
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— — -- AMrejs R.Strikis
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` I ` 85 River View Lane,Centerville,MA 02632-Telephone.(508)790-0920
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