HomeMy WebLinkAbout0119 OLD CRAIGVILLE ROAD - Health 119 Old Craigville Road
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Commonwealth of Massachusetts
- Title 5 Official Inspectoon Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 119 Old Craigville Rd R'
Property Address
Dan Thompson
Owner Owner's Name i
information is
required for every Cent 'lle MA 02632 10-6-15 =
page. C)Wtpwn 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.
A. General Information
1. Inspector: , a
Shawn Mcelroy
Name of Inspector
Upper Cape Septic Services
Company Name
P.O. Box 73
Company Address
E. Falmouth MA 02536
City(rown State Zip Code
1-508-495-0905 S13971
Telephone Number License Number
B. Certification
~ I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluatio by the Local Approving Authority
10-6-15
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.
Qa
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17
r
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s 119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is required for every Centerville MA 02632 10-6-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 Ch1R 15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
System is in good working order with no sign of failure.
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 2C years old*or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Forte.
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is Centerville MA 02632 10-6-15
required for every _
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out'or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ -Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1: System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
"safety and the environment:
`' ❑ Cesspool or privy is within"50 feet of a surface water
- ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System(Form -Not for Voluntary Assessments
M ,. 119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is Centerville MA 02632 10-6-15
required for every
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate "Yes"or"No"to each of the following for all inspections:
Yes No ,
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an over oaded 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 'h day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M , 119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is required for every Centerville.. MA 02632 10-6-15
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ , ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system.passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
` The system fails. I have determined that one or more of the above failure
El 0 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
z necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a-surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area— IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection For
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M s 119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is required for every Centerville MA 02632 10-6-15
page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 2 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 220
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
0, Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is Centerville MA 02632 10-6-15
required for every '
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence,have a garbage grinder? ❑ Yes 0 No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes E 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:
Sump pump? ❑ Yes ® No
Last date of occupancy: 10-2015
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
�M 119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is required for every Centerville MA 02632 10-6-15
page. City[Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information: Owner---pumped 4-2015
Was system pumped as part of the inspection? - ❑ Yes ® No
If yes, volume pumped: I - . gallons
How was quantity pumped determined?
Reason for pumping: Maintenance
Type of System:
® Septic tank,distribution box, soil absorption system
❑ Single cesspool
❑ OverFlow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology.Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank.Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-N13 Trtle 5 Official Inspection Form:Subsurface Sewage Disposal Systerr-Page 8 of 17
Commonwealth of Massachusetts
_ w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
,M 119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is required for every Centerville MA 02632 10-6-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.) F
Approximate age of all components, date installed (if known) and source of information:
1980's
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade:, -• 48"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.):
Good condition.
Septic Tank(locate on site plan):
Depth below grade: 42"feet°
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
Y If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 gal
10"
Sludge depth:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection For
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
wM 119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is required for every Centerville MA 02632 10-6-15
page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
22"
Scum thickness 0
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? Tape
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet inver, evidence of leakage, etc.):
Tank is in good condition with baffles installed and no sign of leakage.
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 cutlet tee or baffle
Distance from bottom of scum to botlom of outlet tee or baffle
Date of last pumping:
Date
t5ins•W3 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
u Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is required for every Centerville MA 02632 10-6-15
page. City/Town _ State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is required for every Centerville MA 02632 10-6-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
q
Depth of liquid level above outlet invert N/A
p
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
a
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
,M 119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is required for every Centerville MA 02632 10-6-15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
® leaching pits number: 1-1000 gal
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number,dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding,damp soil, condition of
vegetation, etc.):
Leach pit in good condition and holding water at 36" below inlet invert with stain line at 24" below
invert.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is required for every Centerville MA 02632 10-6-15
page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins-3/13 Title 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
119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is Centerville MA 02632 10-6-15
required for every -
page. CitylTown 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
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t5ins-3/13 s, 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
M 119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is required for every Centerville MA 02632 10-6-15
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: 20
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:
USGS and town maps show groundwater at greater than 20'.
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 16 of 17
Commonwealth of Massachusetts
Tine 5 Official Inspection Form
o Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
119 Old Craigville Rd
Property Address
Dan Thompson
Owner Owner's Name
information is required for every Centerville MA 02632 10-6-15
page. City/Town 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-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
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COMMONWEALTH OF MASSACHUSETTS F RE.CEIVED
EXECUrTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION L
V 1 9 2002
OF BARNSTABLE
i� EALTH DEPT.
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE°fSEWAGE DISPOSAL SYSTEM FORM aA
PART A MAP
CERTIFICATION
PARCEL . 3 -
Property Address: 119 OLD CRAIGVILLE RD HYANNIS,MA 02601 LOT
Owner's Name: O'CONNOR
Owner's Address: 4 WINSLOW RD WESTWOOD MA 02090
Date of Inspection: 10/21/02
rj
Name of Inspector: (please print) , a,!:'; JOVN GRACI cap
Company Name: SEPTIC ►NSPECTIONSIAc-
Mailing Address: P.O.BOX 2119 TEATICKET, MA. 02536
Telephone Number: 508-564-6813'FAX'508-564-7270
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is
true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and
experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system
inspector pursuant to Section 0 340 of Title'5(310 CMR 15.000). The system:
X Passed
_ Condition(aes
_ Needsation by the Local Approving Authority
Fails.,:: ,
tInspector's Signature: Date: 10/21/02The system inspector shall submi as 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 ofthc DEP. The original should be
sent to the system owner and copies,sept to.the buyer, if applicable,and the approving authority.
Notes and Comments ,
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE..
I
****This report only describes conditions at the time of inspection and under the conditions of use at that lime-This
inspection does not address how the system'.will perform in the future under the same or different conditions of use.
"i
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TitIF S Incnnrtinn rnrm (/I,;iMnri11'
Page 2 of 11
rz
OFFICIAL INSPECTION`FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 119 OLD,CRALGVIL'L'ErRD HYANNIS,MA 02601
Owner: O'CONNOR
Date of Inspection: 10/21/02
Inspection Summary: Check A,B,C,D,or E/ALWAYS complete all of Section D
A. System Passes: 1.
X I have not found any information whicl.indicates that any of the failure criteria described in 310 CMR 15.303 or in 310
CMR 15.304 exist. Any failure criteria not,evaluated are indicated below.
Comments:
SYSTEM PASSED TITLE V INSPECTION. RECOMMEND PUMPING EVERY TWO YEARS TO PROLONG THE
SYSTEM'S USEFUL LIFE.
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,�4s approved by the Board of Health,will pass.
Answer yes, no or not determinedh(Y N ND)'`inl"ihe for the following statements. If"not determined" please explain.
Y
n/a The septic tank is metal and'oyer'20'years old* or the septic tank(whether metal or not)is structurally unsound,exhibits
substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced
with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating
that the tank is less than 20 years old'is available.
F
ND explain: n/a
n/a Observation of sewage backup or breakout 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
t .
Health):
_ broken pipe(s)are replaced
_ obstruction is removed
_ distribution box is leveled or replaced
ND explain: n/a
n/a The system required pumping more tha,4times a year due to broken or obstructed pipe(s).The system will pass
inspection if(with approval of the Board`of Health):
_brpk'en pipe(s)'are replaced
_.obstruction is removed
ND explain: n/a
Page 3 of I 1
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 119 OLD CRAICVILLE RD HYANNIS, MA 02601
Owner: O'CONNOR
Date of Inspection: 10/21/02
C. Further Evaluation is Required by the`Board of Health:
Conditions exist which require further evacuation 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 mariner.'which WJ-11 protect public health,safety and the environment:
_ Cesspool or privy is With idS..0`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 Supplizr, f 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 sail 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.
td
_ ess than 100 feet but 50 feet or more from a private water
The system has a septic tank and SAS"and the SAS is l
supply well". Method used to determine distance n/a
"This system passes if,he'well water;analysis,performed at a DEP certified laboratory,for coliform bacteria and
volatile organic compounds`indica es that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy
of the analysis must be,atfached't6+,his form.
3. Other:
n/a
0.:
Page 4 of I I
s
OFFICIAL INSPECTION'FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
E CERTIFICATION(continued)
Property Address: 119 OLD CRAIGVILLE:RD HYANNIS, MA 02601
Owner: O'CONNOR
Date of Inspection: 10/21/02
D. System Failure Criteria applicable to all systems:
You mmt indicate"yes"or"no"to,each,of the,following for all-inspections:
Yes No
_ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
X Discharge or ponding of effluent to-the surface of the ground or surface waters due to an overloaded or clogged
SAS or cesspool
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 day flow
X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times
pumped nLa.
X Any portion of the SAS,cesspool or privy is below high ground water elevation.
_ X Any portion of cesspool o'r privy is'within 100 feet of a surface water supply or tributary to a surface water supply.
X Any portion of wcesspool or,privy i ,Within a Zone I of a public well.
X Any portion of a cesspool or'privy is within 50 feet of a private water supply well.
X Any portion of a cesspool or pricy is,less than 100 feet but greater than 50 feet from a private water supply well with
no acceptable water quality analysi`"s. [This system passes if the well water analysis,performed at a DEP
certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free
from pollution froinl,that facifity,'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 forma
(Yes/No)The system'fails. I have determined that one or more of the above failure criteria exist as described in 310
CMR 15.303,therefore the system}'fail ` The.system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E. Large Systems: i
To be considered a large system the s Mu
st ust serve a facility with a design flow of 10,000 gpd to 15,000 gpd.
You must indicate either"yes"or"no",to each'of the following:
(The following criteria apply to large sysfe's in addition to the criteria above)
3
yes no
X the system is within 400 feet of a surface drinking water supply
s.
X the system is within 200 feet of a tributary to a surface drinking water supply
X the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—I W PA)or a mapped
Zone 11 of a public wafer supply well
If you have answered ,yefsF too any question in Section E the system is considered a significant threat,or answered
" arge system has failed. The owner or operator of any large system considered a significant threat
yes" in Section D above the l
under Section E or failed under Section D shall upgrade the system in accordance with 310 CMIZ 15.304. The system uwufr
should contact the appropriate regional office of the Department.
"alp,,
Page 5 of 1 I
c ,
OFFICIAL INSPECTION,FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 119 OLD CRAIGVILLE RD HYANNIS, MA 02601
Owner: O'CONNOR
Date of Inspection: 10/21/02
Check if the following have been done.You'must indicate "yes"or"no" as to each of the following:
Yes No
X _ Pumping information was provided by the owner,occupant,or Board of Health
r;
X Were any of the system components;pumped out in the previous two weeks
X Has the system received normal flows in the previous two week period `'
X Have large volumes of water been introduced to the system recently or as part of this inspection'?
X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A)
X _ Was the facility or dwOl rig i'nspecte€1,for signs of sewage back up?
X _ Was the site inspected for signs of break out'?
X _ Were all system components,excluding the SAS, located on site'?
X _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the
baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum`?
X Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance
of subsurface sewage disposal systems...
The size and location of,the,,Soil Absorption System (SAS)on the site has been determined based on:
Yes no
X _ Existing information. For'example,`a plan at the Board of Health.
X _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is
unacceptable)[310 CMR 15.302(3)(b)]
"it
Page 6 of I 1 ,•„
4'*;
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE"SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
. SYSTEM INFORMATION
Property Address: 119 OLD CRAIGVI'LLE RD HYANNIS, MA 02601
Owner: O'CONNOR
Date of Inspection: 10/21/02
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):,2`` Number of bedrooms(actual): 2
DESIGN flow based on 310 CMR"15.203'(for,example: 110 gpd x#of bedrooms): 220
Number of current residents: n/a
Does residence have a garbage grinder(yes or no): NO
Is laundry on a separate sewage system(yes or no): NO [if yes separate inspection required]
Laundry system inspected(yes or no)-.;NO
Seasonal use:(yes or no): NO i
Water meter readings, if available'(last 2 years usage(gpd)): a 0 Z i Q) ��U
Sump pump(yes or no): NO t
Last date of occupancy: n/a 01 - R
U 0 _V V C (X�/
$� N
COMMERCIAL/INDUSTRIAL
Type of establishment: n/a o
Design flow(based on 310 CMRe15:203) n/agpd
Basis of design flow(seats/persons/sgft,etc.): n/a
Grease trap present(yes or no): NO ,�,,
Industrial waste holding tank,present(yes,or no): NO
Non-sanitary waste discharged`to the'Title'5 system(yes or no): NO
Water meter readings, if available: n/a .
Last date of occupancy/use: n/a
OTHER(describe): n/a f
}.,;:'°GENERAL INFORMATION
Pumping Records
Source of information: n/a
Was system pumped as part of?he inspection,(.yes or no): NO
If yes,volume pumped: n/agallons .How was`quantity pumped determined? n/a
Reason for pumping: n/a f ',
TYPE OF SYSTEM
X Septic tank,distribution box,soil absorption system
_Single cesspool
_Overflow cesspool
_Privy
_Shared system(yes or no)(if yes,,.attach.nrevious inspection records, if any)
_Innovative/Alternative technology. Attac a copy of the current operation and maintenance contract(to be obtained liven
h
system owner)
_Tight tank Attach a copy of the DEP approval
Other(describe): n/a
Approximate age of all components,date installed(if known)and source of information:
1962 BY AGENT
Were sewage odors detected when-arriving at`the site(yes or no): NO
f„ A
4
,Page 7 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 119 OLD CRAIGVILLE RD HYANNIS,MA 02601
Owner: O'CONNOR
Date of Inspection: 10/21/02
BUILDING SEWER(locate on site plan)
Depth below grade: 10"
Materials of construction:_cast iron _40 PVC_other(explain): n/a
Distance from private water supply well or suction line: n/a
Comments(on condition of joints,venting,ev;dence of leakage,etc.):
TOWN WATER
SEPTIC TANK: X(locate on site plan)
Depth below grade: 4"
Material of construction: Xconcrete_metal_fiberglass_polyethylene other(explain)n/a
If tank is metal list age: n/a Is age eonfifrn d by a Certificate of Compliance(yes or no): NO(attach a copy of certificate)
Dimensions: 1000 GALLONS', (,,
Sludge depth: 2"
Distance from top of sludge to bottom of ouaet,tee or baffle:32"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle: 6"
Distance from bottom of scum to bottoin of outlet tee or baffle: 17"
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.):
SEPTIC TANK AND ALL COMPONENTS ARE STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.
RECOMMEND PUMPING EVERYJWO YEARS TO PROLONG THE SYSTEM'S USEFUL LIFE.
GREASE TRAP:_(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal—fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a
Scum thickness: n/a
Distance from top of scum to top`of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Date of last pumping: n/a
Comments(on pumping recommenda ntegrity, liquid levels as related
recommendation's, inlet,and outlet tee or baffle condition,structural i
to outlet invert,evidence of leakage,'etc.);
n/a
11
c.
•vP �.
{ i
Page 8 of l l i
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 119 OLD CRAIGVILLE'RD HYANNIS,MA 02601
Owner: O'CONNOR
Date of Inspection: 10/21/02
TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan)
Depth below grade: n/a
Material of construction:_concrete_metal__fiberglass_polyethylene_other(explain): n/a
Dimensions: n/a7;,
Capacity: n/a gallons , 47
Design Flow:n/a gallons/day
Alarm present(yes or no): N/A
Alarm level: N/A Alarm in working'order(yes or no): NO
Date of last pumping: n/a <,
Comments(condition of alarm and float switches,etc.):
n/a
DISTRIBUTION BOX: _(if present must;be opened)(locate on site plan)
Depth of liquid level above outlet invert: n/a
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover, any evidence of leakage into
or out of box,etc.): �.
n/a
PUMP CHAMBER: _(locate on site plan)
Pumps in working order(yes or no)`.NO'
Alarms in working order(yes or no):NO
Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.):
n/a ,..
. e
r
x
Page 9 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 119 OLD CRAIGVILLE RD HYANNIS, MA 02601
Owner: O'CONNOR
Date of Inspection: 10/21/02
SOIL ABSORPTION SYSTEM (SAS): X (locate on site plan,excavation not required)
F
If SAS not located explain why:
n/a
Type
1000 GAL 6' X 6' leaching pits, number: 1
n/a leaching chambers, number: n/a
n/a leaching galleries, number: n/a
n/a leaching trenches, number, length: n/a
n/a teaching fields, number: n/a
n/a overflow cesspool, number: n/a
n/a , innovative/alternative system
Type/name of technology: n/a
Comments(note condition of soil,,ys'ignsWhydraulic failure, level of ponding,damp soil,condition of vegetation,etc.):
LEACH PIT IS STRUCTURALLY SOUND AND FUNCTIONING PROPERLY.SYSTEM SHOWS NO SIGNS OF
FAILURE. PIT WAS EMPTY AT TIME OF INSPECTION.STAIN LINES INDICATE PIT HAS NEVER HAD
MORE THAN 2' OF LIQUID IN IT. BOTTOM IS AT 1016".
CESSPOOLS: (cesspool must be pumped as�part of inspection)(locate on site plan)
Number and configuration: n/a
Depth—top of liquid to inlet invert: n/a.
Depth of solids layer: n/a
Depth of scum layer: n/a
Dimensions of cesspool: n/a
Materials of construction: n/a -�
Indication of groundwater inflow(yes or no):;NO
Comments(note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
n/a
PRIVY: (locate on site plan)
Materials of construction: n/a
Dimensions: n/a
Depth of solids: n/a
Comments(note condition of soil,,signs of hydraulic failure, level of ponding,condition of vegetation,etc.):
� I '
Q
Page 10 of I I
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 119 OLD CRAIGVILLE RD HYANNIS,MA 02601
Owner: O'CONNOR
Date of Inspection: 101211d
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch of the sewage disposal'syste0including ties to at least two permanent reference landmarks or benchmarks.
Locate all wells within 100 feet. Locate where public water supply enters the building.
I � /
AA 3q
6i3 Zvi
r.t ,
in
Page I 1 of I 1
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 119 OLD CRAIGVILLE RD HYANNIS,MA 02601
Owner: O'CONNOR
Date of Inspection: 10/21/02
SITE EXAM
_Slope
_Surface water
_Check cellar
Shallow wells
Estimated depth to ground water 12+feet .
Please indicate(check)all methods used To determine the high ground water elevation:
NO Obtained from system design plans on record- If checked,date of design plan reviewed: n/a
YES Observed site(abutting property/observation hole within 150 feet of SAS)
NO Checked with local Board of Health-explain: n/a
NO Checked with local,'dxcavatdrs, installers-(attach documentation)
NO Accessed USGS database-explain,: /a
You must describe how you established`the high ground water elevation:
HAND AUGER- 12+FT.
LOCATION SEWAGE PERMIT NO.
//9 J/c/
VI,LL//AGE
A & B CESSPOOL SERVICE
128 BISHOPS TERRACE, HYANNIS, MA 02601
BUILDER OR OWNER
DATE PERMIT ISSUE
DATE COMPLIANCE ISSUED
\&Y �
r �
P
r
cr
----------------
� N
d
r.
^ti
v
No.............:.......� Fxs..�...15.00.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T own..........0 F..........................................Barnstable
................................................
Applira#ion for Uiipuiitt1 Mirka Tontitrurtiun trnti#
Application is hereby made for a Permit to Construct ( ) or Repair ( x) an Individual Sewage Disposal
System at:
119 Old Craigville Roads Hyannis,_n
........ ...•-•-•• .... ....-•-••--••---------------••---•--••---•---••......•••...•-•-•---•-.......-••---••---•--•••-.
Location-Address or t No.
Paul L. Bisho. 119 Old Craigville Hyannis, MA 02601
...--•--•......••--...... ...----•-....... ..... .... - -• ••-
w A & B Cesspool Service 128 Bishops_ Terrace ddHyannis , MA 02601
Installer � Address
dType of Building Size Lot...... Sq. feet
Dwelling—No. of Bedrooms......_...3...............................Expansion �ttic ( ) Garbage Grinder ( )
Other—Type of Building No. of persons............................ Showers —
a YP g -------------•-•----------•• P ( ) Cafeteria ( )
Q' Other fixtures .......................... •..............
---.. -
w Design Flow............................................gallons per person per day. Total daily flow.._.........................................gallons.
C4 Septic Tank—Liquid*capacity............gallons Length................ Width................ Diameter---------------- Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
4 Test Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water........................
0-4 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
a ----------------- ---...--------------•--•----------------......................•-•••-•.....-•-.........---•-•----•--•...----••................--------
ODescription of Soil.................Sand...............................................•-•--•-•------
x
U ..-------•---------------•------•--•--•••-••---•.......--------............-•--•-••----....---------•....••-------------------------•-----------•--...........•--.......-••.....---••------.............
w, --------------- ----------------------------------------------------------------------------------------------••------------......--...----•---------------------------------------------_:•-•-••--=--
VNature of Repairs or Alterations—Answer when applicable_�x�S_ta llatioxz__.Q�..a..] ,QQO--g�-] oz�a--.gre-cast
..st-me... lx).............•-•--•-----•-----=-•--.....-------------------------------•-------._._.......---•--•---•---••-•---••-•-•---
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of ITL.E 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issuued,,by t e boar�doof::'he`alth. ^.
Si ne !` f� . G� /Z/ / 3,02 .�:...._....
g c�
D
Application Approved By.................... !- . ...._.................................. 3/02
Date
Application Disapproved for the following reasons:.................................................................................................................
-•------•-•---•-----•----•••-------------------------- •-----------------....................-------•-•••............---••--••---••-•-------------------------------------•-----•-----------•------......
Date
Permit No......84 ............................................. Issued........... /2/8.4...--••----•--.................
Date
No...-.. F- e � Fxs.. ...15.00.......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
............. . .....Town........-.OF......Barn.stable...........................
Appliratiuu for Mipasal Workii Towitrurtion rrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( X) an Individual Sewage Disposal
System at:
119 Old Craigville Rcad, Hyannis, P'A
-•..._ ••------••- -•-- .... --•.. .....••-•-••....---•--------••-----•----•--••-••--•-•-._...•--------•••-••••--•--••-•--•--........
Location-Address or t No.
PaulL. Bishop 119 Old' Crai ...................................................................................... ...... ..............................
A & P Cesspool SerA er 128 Bishops Terrace, VV annis, MA 02601
,-1 -----------------••-------•----------•------••-•-•---•-•-••••----••---•..
Installer Address
d Type of Building Size Lot............................Sq. feet
Dwelling—No. of Bedrooms............................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
dOther fixtures ------------------------------------------------•----------------•--------•-•-------••----•------•••-••••---••-•----•--••-...•--••-••-...............
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
PG Septic Tank—Liquid capacity............gallons Length................ Width................ Diameter................ Depth................Disposal Trench—No..................... Width.................... Total Length.................... Total leaching area....................sq. ft.
x
Seepage Pit No------------- ----- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
aPercolation Test Results Performed by.......................................................................... Date........................................
Test Pit No. I................minutes per inch Depth of Test Pit.................... Depth to ground water........................
fs, Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
P1 ..------•-----------------------------------------••----------------•-----------...------...._.......-----...--------•---........---•---•--•-•---...---....•-
ODescription of Soil.................,.Md.............................................................................................................................................
U •--------------••-----------•-------•--•--...-----...-•--------••••---•---••-•---••-••-•••.....--•------....•--•-•-•••-••----•--•••••-----•------••-----••--...........................................
W .......................... - -------- - - -- - ---------------------------•------------------------------------------------------------------------------------------------._...........•..
U Nature of Repairs or Alterations—Answer when applicable-insta,llationof•-8_-1,000••ga llOn�--- z!e-east
stone...Packed_-leach..Pit...(oveflgO•,
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,b issued>xy the b a>7d of, 1t I.
E ,
Signed ` `mil 1--- - -- .......
�.. ..-.•3�02/84
........ ....... -.. ............
Application Approved By---•------•••--•-•--c --•••••----••••......................... ..........31.02 ----........
Date
Application Disapproved for the following reasons:................................................................................................................
--•-•--•...--------•-•••-•--••-•-•-•-•----•-•-•-•-•-••---•---••••••----••-----•-••--••-••.-._...•....•....-...-..•....•-•••••-----•--••-•-•••-•---••---•--•••-•--•--•--•- •---•--•----•---•--•...---
Date
Permit No. �. .:----•••_.. Issued 3� ��----...---•---•----------------
l
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
T own Barn stable
..........................................O F..................................................................................... ?``
(Irrtif irate of Tomplinurr t
THIS IS TO CERTIFY, That the Individual Sewage Disposal System construct d ( ) or Repaired (X )
by A & B Cesspool Service, 128 Bishops Terrace, Hyannis, t o 0'Ot 1;
......................................................
at 119.Old Craigville Rd., Hyannis, MA 'f3` 66r1 - Paul Bishops
- • - • •••-•••---•----•--•---•-•-----------•---------------------------•-•-----•-------•-----------•-•--•-••-...-•••••••••••-•-
has been installed in accordance with the provisions of TJTLF 5 of The State Sanitary /described in the
application for Disposal Works Construction Permit No."� •--��_.�._.--••.••-•-•-•_••- dated3� (..'."•......_..___••.-•.--.-•..... \
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE....................................... Inspector........ 1
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
Town Barnstable
84_ /6 6 OF.....................•.. - ...--....-.-..-.-.... $ 15.00
No..................•...... FEE........................
Diupuuut Workv Tonotrnrtion rrmit
Permission is hereby granted........A & B Cesspool Service
to Construct or Repair X ) an Individu Sewage Disposal 'System
61
) ( a1
at No.......... l7ld Craigville Rd., Hyannis -- _PAu_1 L. Bishop
---------------------•-------------•---.--...-•--------•---------------••-.•...........
Street
as shown on the application for Disposal Works Construction Perm• No.. .................. Dated....
DATE. Board of Health
�.
FORM 1255 A. M. SULKIN, INC., BOSTON ��`