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Home My WebLink About0554 OLD STRAWBERRY HILL ROAD - Health 554 Old Strawberry-Hill- Hyannis 1 A= 273 — 105 4 I 1 it i, No. f l Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Zipplitatlon for Disposal 6pstem Construttion Permit Application for a Permit to Construct( ) Repair(' Upgrade( ) Abandon( ) ❑Complete System Individual Components Loc dd ss or Lot No. 3 ��, sc r-�yer� Owner's Name,Address,and TeL No. Asses�so�r� ap/Par�crel 2- 3 A i®S A CA 01 %ax "C42 Instac�ller' Name,Address,and (e�l._No. TZ, Designer's Name,Address,and Tel.No. M�®+e.� �y�Z°.• `'a r1d�� W S✓�.'� �y�-fir®1/.� Type of Building: Dwelling No.of Bedrooms Lot Size ® sq.ft. Garbage Grinder( ) 0 Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) A/P,'4/ Qr< ke\?' tT Date last inspected: Agreement: The undersigned agrees to ensure the construction and ma' nance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme ode and not to place the system in operation until a Certificate of Compliance has been issued by this Boa f H h x Signed Date ,Z^ y—1 Application Approved by Date /�L—/L( —f 5 Application Disapproved by Date for the following reasons Permit No. V 15 — L I Date Issued 1 Rw No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS 01ppYication for Misposal 6pstem Cons"ttion Permit Application for a Permit to Construct( ) Repair VUpgrade( ) Abandon( ) ❑Complete System Individual Components C `dd ss or Lot No. p� `SC Owner's Name,Address,and Tel.No. �hC �%e- Ih b o o. 1�o�( Assessor's ap/Parcel �-73 1 o S L,6000( j Installer's Name,Address,and lel.No. "tq� (.,� �b`P,� Designer's Name,Address,and Tel.No. ipx a?AAA2 CS49) t - 2. _ Type of Building: �v Dwelling No.of Bedrooms Lot Size p'LOCO ^_sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. ' Description of Soil Nature of Repairs or Alterations(Answer when applicable) �nS��,1\ A/�'.�.� �^' ac►c �tl�Z ? 9 P_ Date last inspected: Agreement:' IT-he undersigned agrees to ensure the construction and ma' nance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environme ode and not to place the system in operation until a Certificate of Compliance has been issued by this BA e h. '(Signed ;r Date )7-I y—I r Application Approved by f Date O--I N Application Disapproved by Date for the following reasons Permit No. cl f2 — Date Issued — -1 — J THE COMMONWEALTH OF MASSACHUSETTS BARN STABLE,NSTABLE,MASSACHUSETTS CPCtIfILatP Of �oYtYpYIattLP THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired(V<," Upgraded( ) Abandoned( )by 'tot"-, Ct k t<-r k _T GtL 114rk� C,.Q y at SS� O�� $�rca�whc ., a has been con cted in accordance / with the provisio s of Title 5 ad-tife for Disposal System Construction Permit No. 0( r�ated 0 r lG Installer Designer. .� #bedrooms Approved desi?ncti,)h / gpd The issuance o this pbrmit shall not be construed as a guarantee that the system will as designed. Date ( Inspector / --------------------------'--/----------------------------------------------------------------------------------------------------------- No. "y Fee THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal 6pstem Construction Permit � Permission is hereby granted to Construct( Re air( ) Upgrade( ) Abandon( ) System located at �3 1 and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Construction must be completed within three years of the date of this permi Date )N 5 Approved by i- - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 554 Old Strawberry Hill Rd9 Property Address Dennis March ant P.O Box 442 Barnstable MA 02632 � Owner Owner's Name N information is t� required for every Hyannis MA 02601 12/7/15 Url page. Cityrrown State Zip Code Date of Inspection �a Inspection results must be submitted on this form. Inspection forms may not be altered in kr§y way. Please see completeness checklist at the end of the form. Important:When 1�3 filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not Jason Burnie use the return Name of Inspector key. JB Septic Inspections and consultation Company Name 248 Camp St UnitX4 Company Address rem W.Yarmouth MA 02673 Cityrrown State Zip Code 774-268-0857 S5011 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 12/7/15 Inspector's Signatur 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•3/13 Tille 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts = Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Old Strawberry Hill Rd Property Address Dennis Marchant P.O Box 442 Barnstable MA 02632 Owner Owner's Name information is required for every Hyannis MA 02601 12/7/15 page. Cityrrown 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 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: Upon inspection I found that the original plan dated 1979 and a previous Title V report showed differing information that what I actually found in the ground. Yet the system as found, was determined to be a conditional pass. I, Jason Burnie talked with the town and it was determined that a new distribution box and piping from the outlet of the septic tank all the way through to the leach pit needed to be replaced. These were done to increse the capacity of the septic tank and also the capacity of the SAS. Those repairs were done in agreement with the Town of Barnstable's approval (Permit# ) 13) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old"or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 554 Old Strawberry Hill Rd Property Address Dennis Marchant P.O Box 442 Barnstable MA 02632 Owner Owner's Name information is required for every Hyannis MA 02601 12/7/15 page. Citylrown 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 (cunt.): ❑ 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 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M 554 Old Strawberry Hill Rd Property Address Dennis Marchant P.O Box 442 Barnstable MA 02632 Owner Owner's Name information is required for every Hyannis MA 02601 12/7/15 page. Citylrown 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 colifdrm 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 1/day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 554 Old Strawberry Hill Rd Property Address Dennis Marchant P.O Box 442 Barnstable MA 02632 Owner Owner's Name information is required for every Hyannis MA 02601 12/7/15 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 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 554 Old Strawberry Hill Rd Property Address Dennis Marchant P.0 Box 442 Barnstable MA 02632 Owner Owner's Name information is required for every Hyannis MA 02601 12/7/15 page. Citylrown 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): unknown Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): unknown t5ins•3/13 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 �M ,'0 554 Old Strawber Hill Rd Property Address Dennis Marchant RO Box 442 Barnstable MA 02632 Owner Owners Name information is required for every Hyannis MA 02601 12/7/15 page. Ctty/Town State Zip Code Date of Inspection D. System Information Description: The system consists of a septic tank destribution box and a 4' leach pit Number of current residents: 0 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ® Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): 15= 129gpd Detail: 14= 102gpd Sump pump? ❑ Yes ® No Last date of occupancy: Vacant appx 1 year 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 554 Old Strawb erry Hill Rd Property Address Dennis Marchant P.O Box 442 Barnstable MA 02632 Owner Owner's Name information is required for every Hyannis MA 02601 1217/15 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: Customer- pumped last year Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M 554 Old Strawberry Hill Rd Property Address Dennis Marchant P.O Box 442 Barnstable MA 02632 Owner Owner's Name information is required for every Hyannis MA 02601 12/7/15 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: 1979 per info available at the Barnstable BOH Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: 50' feet Comments(on condition of joints, venting, evidence of leakage, etc.): Water was verified coming into the tank. Septic Tank(locate on site plan): Depth below grade: Inlet- 1' Outlet- 10" 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: 1000gal Sludge depth: 2 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 554 Old Strawberry Hill Rd Property Address Dennis Marchant P.O Box 442 Barnstable MA 02632 Owner Owners Name information is required for every Hyannis MA 02601 12/7/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 2+ Scum thickness 1" Distance from top of scum to top of outlet tee or baffle 4"+ Distance from bottom of scum to bottom of outlet tee or baffle 1'+ How were dimensions determined? tape measure 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 septic tank was at a normal level 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-3/13 Title 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 s 554 Old Strawberry Hill Rd Property Address Dennis Marchant P.O Box 442 Barnstable MA 02632 Owner Owner's Name information is required for every Hyannis MA 02601 12/7115 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 554 Old Strawberry Hill Rd Property Address Dennis Marchant P.O Box 442 Barnstable MA 02632 Owner Owner's Name information is Hyannis MA 02601 12/7/15 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" 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 new distribution box is an H-20 with the cover to within 6"to grade. This was installed per permit 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: SAS was located t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts F Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ,M 554 Old Strawberry Hill Rd Property Address Dennis Marchant P.O Box 442 Barnstable MA 02632 Owner Owner's Name information is required for every Hyannis MA 02601 1217/15 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 1-6'Wx 4'D with 2' of stone ❑ 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.): The leach pit was found to be dry upon inspection. There was some staining in the pit over the old pipe invert. That pipe was 2'from the bottom of the pit which was causing the pit to only be at half capacity. Since adding new pipe we have added elevation which in turns adds capacity to the leaching. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 554 Old Strawberry Hill Rd Property Address Dennis Marchant P.O Box 442 Barnstable MA 02632 Owner Owner's Name information is required for every Hyannis MA 02601 12/7/15 _ page. Citylrown 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•3113 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 554 Old Strawberry Hill Rd Property Address Dennis Marchant P.O Box 442 Barnstable MA 02632 Owner Owner's Name information is Hyannis MA 02601 12/7/15 requirey d for every page. CityTrown 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 I I o c t� o � Q A _ C : a3 1� D � p ` e' 3r, a 33 ` 6 '' 9.a'6 .r t5ins•3113 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 554 Old Strawberry Hill Rd Property Address Dennis Marchant P.O Box 442 Barnstable MA 02632 Owner Owner's Name information is required for every Hyannis MA 02601 12/7/15 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'+ per original plan dated 1979 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: 1979 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: Per information on the original plan and also observing other plans from neighboring properties groundwater has been determined to be at least 20' below grade. From grade to the botom of the SAS you have a total depth of 68". This gives you almost a 15' seperation from bottom of SAS and to where groundwater is known not to be. 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 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 554 Old Strawberry Hill Rd Property Address Dennis Marchant P.O Box 442 Barnstable MA 02632 Owner Owner's Name information is required for every Hyannis MA 02601 12/7/15 page. Citylrown 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 I t5ins•3/13 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 n. COMMONWEALTH OF MASSACI USETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL D JUN 1 5 Z004 TOWN OF BARNSTABLE HEALTH DEPT. TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 554 Old Strawberry Hill Road PuIAP Centerville, MA PARCEL , 1 Owner's Name: Scott Dupuis , Owner's Address: p t OT Date of Inspection: Name of Inspector:(please print)wi1 1 i am . Robinson Sr. Company Name: William E. Robinson Septic Service Mailing Address: P O Box 1 089 Centerville MA Telephone Number: (508) 775-8776 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 15340 or Title 5(310 CMR 15.000). The system: asses Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: �� g° .ice � Bute: 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. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that. time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page I ' t Page 2 of 11 ' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE-SEWAGE DISPOSAL SYSTEM INSPECTION FORM r PART A " CERTIFICATION(continued) Property Address: 554 Old Strawberry Hill Road Centerville, MA Owner.• Scott Dunuis Date of Inspection: Inspection ummary: Check A,B,C,D or E/ALWAYS complete all of Section D A. Sy em Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. Syste Conditionally Passes: One more system components as described in the"Conditional Pass"section need to be replaced or repaired.The stem,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no not determined(Y,N,ND)in the for the follow explain. ing statements.if"not determined"please The septic is metal and over 20 years old"or the septic tank(whether metal or not)is structurally unsound,exhibits s bstantial infiltration or exfrltration or tank failure is imminent.System will pass inspection if the existing tank is repl ced with a complying septic tank as approved by the Board of Health. •A metal septic will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the is less than 20 years old is available. ND explain: Observation f sewage backup or break out or high static water level in the distribution box due to-broken or obstructed pipes)o due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board f Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The Sys cm required pumping more than 4 times a year due to broken or obsaticted pipe(s).The system will pass inspectio if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is nmovcd ND explain: i Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 554 Strawberry Hill Road Centerville, MA Owner: Scott Dupuis Dale of Inspection:_ '/�/,L_ p cam_ C Furthcr Evaluation is Required by the Board of Health: ditions exist which require further evaluation by the Board of Health in order to determine if the system is failing t rotect public health,safety or the environment. I. Syste will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the syste is not functioning in a manner which will protect public health,safety and the environment: — Ce spool or privy is within 50 feet of a surface water Cc pool or privy is within 50 feet of a bordering vegetated wetland or,a salt marsh 2. System v fill fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is fu lioning in.a manner that protects the public health,safety and environment: _ Th system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface ater supply or tributary to a surface water supply. system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. __.. T ie system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ e system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more frond a priv to water supply well** Method used to detertine distance " his system passes if the well water analysis,performed at a DEP certified laboratory, for coliform b cteria and volatile organic compounds indicates that the well is Gee from pollution from that facility and e presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 provided that no other ` failure criteria are triggered.A copy of the analysis must be attached to this form. 3. ther: 3 r. Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Properly Address: 554 Old Strawberry Hill Road Centerville, MA Owner: Scott Dupuis Date of Inspection: �Z_ D. System Failure Criteria applicable to all systems: You mlitst indicate"yes"or"no"to each of the following for all inspections: Yes N 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 _ tatic liquid level in the distribution box above.outlet invert due to an overloaded or clogged SAS or esspooi iquid depth in cesspool is less than 6"below invert or available volume is less than'/,day flow equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number f times pumped y portion of the SAS,cesspool or privy is below high ground water elevation. y portion of cesspool or privy is within 100.feet of a surface water supply or tributary to a surface •ater supply. y portion of a cesspool or privy is within a Zone I 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 Net from a private eater supply well with no acceptable water quality analysis.(This system passes if lice well water analysis, performed at a DEC certified laboratory,for coliform bacteria and volatile organic compounds Indicates that(lie well is free from pollution from that facility and lire presence of antmonla 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.] (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system tilt system must serve a facility with a design now of 10,000 gild to 15,000 hpd• You m st indicate either"yes"or"no"to each of the following: (The f llowing criteria apply to large systems in addition to die criteria above) yes o 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 I I of a public water supply well If, o have answered" es"to a question idered tgn a s' iftcant due answered y y any q sUon in Section E du system is cats at,or "yes' in Section D above the large system has failed.The inmer or operator of any large system considered a signi cant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.30 .The system owner should contact the appropriate regional office of the Department. 4 Page S of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 554 Old Strawberry Hill Road en ervi Ile, Owner: Scott Dupuis Date of Inspection: — Check if the following have been done.You must indicate"Yes"or"no"as to each of the following: Yes o _ Pumping information was provided by the owner,occupant,or Board of Health `i/Wcre any of the system components pumped out in the previous two weeks? v — 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: Yes no _ ✓Existing information.For example,a plan at the Board of Health. Z_ 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)J S Page 6 of I OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:554 Old Strawberry Hill Road Centerville, MA Owner: Scott Dupuis Date of Inspection:_ FLOW CONDITIONS RESIDENTIAL. Number of bedrooms(design):. Number of bedrooms(actual):�U DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x N of bedrooms): S L> Number of current residents: Does residence have a garbage grinder(yes or no): 4- D Is laundry on a separate sewage system(yes or no):o [if yes separate inspection required] Laundry system inspected(yes or no): d Seasonal use:(yes or no):!a- d Water meter readings,if available(last 2 years usage(gpd)): N)A Sump pump(yes or no): ti v Last date of occupancy: C011IME IAL/INDUSTRIAL Type of esta lishment: Design flow based on 310 CUR 15.203): gpd Basis of des' flow(seats/persons/sgft,etc.): Grease trap resent(yes or no):_ Industrial sic holding tank present(yes or no):_ Non-sani waste discharged to the Title 5 system(yes or no):— Water m er readings,if available: Last dat of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: l 9' 9 i p- 0Was system pumped as part of the inspection(yes or no):�D If yes,volume pumped: gallons--How was quantity pumped determined? Reason for pumping: TYPTxOF 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) Tight tank Attach a copy of the DEP approval _Other(describe): Approximate age of all components,date installed(if known).and source of information: Were sewage odors detected when arriving at the site(yes or no).,i 6 Rage 7 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 554 Old Strawberry Hill Road Centerville, MA Owner:_ Scott Dupuis Date of Inspection: 4 z BUILDING SEA R(locate on site plan) Depth below grade Materials of const ction:_cast iron _40 PVC_other(explain): Distance from pri ate water supply well or suction line: Comments(on c ndition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: '✓(locate on site plan) Depth below grade: t � Material of construction: ✓concrete metal fiberglass polyethylene _othcr(explain) _ _ — If tank is metal list age:— Is age confirmed-by a Certificate of Compliance certificate) , P (yes or no):_(attach a copy of Dimensions: ri °z G C Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: �' Scum thickness: u Z 112 �— Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: �l How were dimensions determined: Q ��,� Comments(on pumping recommendations,inlet and outlet ice or baffle conditicn,structural integrity,liquid levels~ as related to outlet invert,evidence of leakage,etc.): GREASE TRAP: (locate on site plan) i Depth below grade Material of cons lion: concrete metal fiberglass—polyethylene—other (explain): — — Dimensions: Scum thickness: Distance from to of scum to top of outlet ice or baffle: Distance from b ttom of scum to bottom of outlet tee or baffle: Datc of lastpu ping: Commenls(o pumpiiig rcconimendations,inlet and outlet ice or baffle condition,structural integrity, liquid levels T' as related to outlet invent,evidence of leakage,etc.): 7 Page 8 of'l OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Properly Address: 554 Old Strawberry Hill Road Centervilre, MA Owner: Scott Dupuis Date or losptction: '- - p V TIGHT or HOLDINTANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material o!'ej : con rete metal fiberglass_polyethylene other(explain). 4 Dimension Capacity. allons Design Floallons/day Alarm pre ): Alarm leveI to working order(yes or no): Date of lasCommentsf al i and float switches,etc.): i DISTRIBUTION BOX: y(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: K)_ 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: (ocate on site plan) Pumps in working order(y s or no): Alarms in working order es or no): Comments(note eonditi of pump chamber,condition of pumps and appurtenances,etc.): f Page 9 of I l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 554 Old Strawberry Hill Road Centerville, MA Owner: Scott Dupuis Date of lospection: ��- 7 SOIL ABSORPTION SYSTEM(SAS): ✓(locate on site plan,excavation not required) If SAS not located explain why: (eaching pits,.number: leaching chambers,number: leaching galleries,number: leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.). � L CESSPOOLS: (cc pool must be pumped as part of inspection)(locate on site plan) Number and configurat' n: Depth—top of liquid t inlet invert: Depth of solids layer Depth of scum laye . Dimensions of ces pool: Materials of cons ction: Indication of gr dwater inflow(yes or no): Comments(not condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: ( cate on site plan) Materials of c struction: Dimensions: Depth of sol' s: Comments note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): 9 Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 554 Old Strawberry Hill Road Centerville, MA Owner: Scott Dupuis Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. �u 10 i 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: 554 Old rawb _rry Hill Road CpntPrvi11P., MA Owner. Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-if checked,date of design plan reviewed: 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: 11 AsBuilt Page 1 of 1 t Page 10 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLU NTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Propt:rty'Address: 554 Old Strawberry Hill Road Centerville, MA Owner: Scott Dupuis Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch 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. v �u M 3 3, 10 http://issgl2/intranet/propdata/prebuilt.aspx?mappar=273105&seq=1 12/4/2015 LO`CAT^h�N ' � SEWA G E PERMIT NO.� i /® did S IrAw it �tl�//�Z�/ Its / 7S VILLAGE r INSTA LLER'S . NAME & ADDRESS kl4f G✓d cry/ w B U I L D E R OROWNER /VV DATE PERMIT ISSU D /2� 4 _ DAT E COMPLIANCE ISSUED t-_ i. �> , � V -y � �V - �?`�� — - Wit'' . � _ � � , � }� �� /� � �-� �c �{ No..........I. .. ._ 0 Fu$.............................. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ............... �l . .....OF......... :.:......----.............................................. Appliration for Bispoii al Works Tonstrurtinn Fermi# Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual,Sewage Disposal System at: 0 ...... ..4 _ %�� .�.. r......._�. L................... ....................../.. ......-----------.................---............------------------.. Loca n-Address or Lot No ..... ..� ...._..... --..... - Y... ....... ...................... -- Owner Vdr s � Installer Address d Type of Building Size Lot...[}_QQ. --.-----Sq. f t V Dwelling—No. of. Bedrooms._ .................................Expansion Attic ( ) Garbage Grinder (( 4► Other—Type T e of Building 0' e.... No. of persons �............... Showers — Cafeteria a yP g --------•------ - P ( J) ( ) Q, Other ures -•-•••..............•--••-----•. W Design Flow........ . ............................gallons per person per day. Total daily flow........'?a0.....................gallons. WSeptic Tank—Liquid capacitylf C)O Ugallons Length................ Width................ Diameter................ Depth................ x Disposal Trench—No.......... ...... Width.... ....... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No........../-------- Diameter......... Depth below inlet................ Total leaching area..x-Q61....sq. ft. Z Other Distribution box ( ) Dosing t nk aPercolation Test Rests Performed by..... __7�......°.//_.Y�'. ................:..... Date..... _.f ...f........... Test Pit No. 1..--_ ......minutes per inch Depth of Test Pit...j�........... Depth to ground water...........:............ Test Pit No. 2................minutes per inch Depth of Test Pit---------------_.... Depth to ground water........................ a --••---•----••••- .of Soil .Q .•-•�-----............._a�C'.................. ------------------------------------------------ V .--•--------------------- --- ---- ------•---fie � ° �� ` 7� e- W UNature of Repairs or Alterations—Answer when applicable................................................................................:.............. ----------------------------•--•----•--------------•----•--•------------------------........-•---••--••••--••••-••••-•----------•••-•---•---•--•---------••--•-•--•-••••--•••••••-•••••--------•---•••-- Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITi U 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued b e b d of health. Signe '..r.•--.-- , LA4 �/1 e Dal Application Approved By-••••-• ....... . .. Date Application Disapproved for the following reasons:_......_...............••-•--••••••--••••----•----•---•---•........................•••••. --------...._ ---------------------------------------=----•------•------...............----•---------...............---......-•---•••-•-••------•---- ........................................................... Date PermitNo......................................................... issued.... ...--...7-----��.-----...._..------- Date ;A ;?y-I'vo No........../7J- Fizz............................ THE COMMONWEALTH OF MASSACHUSETTS ---.,BOARD 9F HEALTH 7 .....OF. ojt2,0k:W.t .............................................. Applit4tion for-Uhiposal Workfi Tow3trurtion Famit Application is hereby made for a Permit to Construct or Repair an Individual Sewage Disposal Sys?temnp Sr Ale ............................ .. .I.......... nA�rd e 5 QV . 0 A .. . ..... ....................................... ... 0.............. ................................................ .... ....... .. ........... .. . ..... ......... Installer Address Type of Build' Size Lot--//J 0.9_�'_)---------Sq. f t U Dwelling��N . of Bedroom Expansior4,Attic =ge Grinder --------------------------- Other—Type of Building ....................;�..... No. of persons............................. Showers Cafeteria PL4 Oth .......................................................0...................................xtures .......................................................... fi, on "I F. Design Flow...... --------------)_.i�....gallons per person per,day. Total"daily flow---------0.(M- ...........................gallons. 9 Septic Tank—Liquid V.......9.gallons Length................ Width................ Diameter----------------- Depth................ Disposal Trench—No .. Width Total Length..__............... Total leaching area....................sq. ft. Seepage Pit No---------I...............Diameter.__....._...._-- .........Depth below inlet....... ........ Total leaching area._C9: (5./ ...sq. ft. z Other Distribution box .( Dosing Percolation Test Re Performed by. .......i-------/------ ....................... Date.... ................I........ �_l P S#� . - 1water_-_-_--______.__:.._.__. �_l Test .it No. I................minutes per inch Depth of Test Pit.12........... Depth to ground Test Pit No. 2................minutes per inch Depth of Test Pit...__......_.__.._.. Depth to ground water...................._... ript ;4 0 Description of Soil 0 '�P Z-6' ...... ... . . .. ---------0 - ....--------PU, ----------------------------------------------- ..................... ....................... .................�.................... ................ .................................................... -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- U Nature of Repairs or Alterations—Answer when applicable----------------_---------------------------------------------------------------------------- ...................................................................................................................................................................................................... Agreement: The undersigned agrees to install the afore6e-scribed Individual Sewage Disposal System in accordance with the provisions of'I'ITT-2 5 of the State"Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has beeXL issued b�ythe bda d of health. g Si ..... ..................................... . ... .. .......... Application Approved By..... . ... .......... --------------------- ------------------ Date Application Disapproved for the following reasons:....................................................................2.......................................... .............1............................................................................................................................................................................... Date PermitNo........................I................................. IssuedL................................. Date THE COMMONWEALTH OF MASSACHUSETTS 4 BOARb', OF HEALTH .......................OF.... 0....................................... (9rdifirate of Tomplialta THISP T8djffLFY, That the Individual Sewage Disposal System constructed or Repaired by.............Z\..!.........;....... -------------------------------------------------------------------*......."-----------------------------------------------------*------------ Ip 'ller at 0-40e ............. been installed in accordance with pro has-----------*------------------------------ 0 h visions of Zl'.11SI/ The State Sanitary C�� d in the , V 41 -7A application for Disposal Works Construction Permit NoO .... . .................... dated-..... .............................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WIL6FUNCTION SATISFACTORY. DATE............. ............................... Inspector... --------------------------- THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH ..................OF.... ................................. No......................... -FEEep..j................ Dispo I Nfrks Tondrudiott Vanfit Q. Permissionis hereby granted.............................................................................................................................................. to Con or Roeair �N an Indivi uaV1eVge.Dispos-ASyA3e3, W/0. 4TOC '�,.,at No .... ........... t 41 ........................................... ....................................................................... .......... Street as shown on the application for Disposal Works Construction Pe t No Dated-----------.........n.- .............. " ............................... j_ 4%%e Board of Hea 1,R—*.....I DATE............................... 7 f..................................... FORM 1255 HOBBS & WARREN. INC.. 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