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Home My WebLink About0085 OLD TOWN ROAD - Health 85 Old Town Road Hyannis A--268 —071 r t� - a tog_ 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 85 Old Town Road Property Address i , Jeanne Macdonald Owner Owner's Nam information is Hyannis Ma 02601 _ 10/15/2020` required for every —page Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way.Please see completeness checklist at the end of the form. Importartt:When A. Inspector Information S l 4P 149 U y filling out forms on the computer, use only the tab Sean M. Jones key to move your Name of Inspector cursor-do not S.M.Jones Title V Septic Inspection use the return Company Name key. 74 Beldan Lane Q Company Address Centerville Ma _ 02632 Cityrrown _ State Zip Code 774-248-4850 smjonesbtle5@gmail.com, SI4522 sean@smjonestitle5.com License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000); 1 have personally inspected the sewage disposal system at the property address listed above;the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 10/15/2020 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 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp.doc-rev.72612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 or 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Old Town Road Property Address Jeanne Macdonald Owner Owners Name information is Hyannis Ma 02601 10/15/2020 required for every y page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: The property located at 85 Old Town Rd Hyannis is served by a Title V septic system consisting of a 1500 gallon septic tank, distribution box and 2 500 gallon precast leach chambers. Although the system was found to be in proper working condition at the time of inspection this report does not guarantee future performance under similar or increased usage. 2) 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): t5insp.doo•rev.7/26=18 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 2 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Old Town Road Property Address Jeanne Macdonald Owner Owner's Name information is Hyannis Ma 02601 10/15/2020 required for every page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ 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): 3) 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. a. 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: t5insp.doc•rev.M612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 18 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments j� 85 Old Town Road Property Address Jeanne Macdonald Owner Owners Name information is required for every Hyannis Ma 02601 10/15/2020 page. City/Town State Zip Code Date of Inspection C. Inspection Summary (coot.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. 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. c. Other: 4) 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 15insp.doc•rev.7/26/2018 Idle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Old Town Road Property Address Jeanne Macdonald Owner Owner's Name information is Hyannis Ma 02601 10/15/2020 required for every -- page. Citylrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow ❑ ® 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 water supply 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 2000 gpd- 10,000 gpd. ❑ ® 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. 5) 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 CA. 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 t5insp.doc•rev.7/26/2018 Tdle 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 18 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Old Town Road Property Address Jeanne Macdonald Owner Owner's Name information is Hyannis Ma 02601 10/15/2020 required for every y page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cunt.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered"yes"to any question in Section CA above the large system has failed.The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section C.4 shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: 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)] t5insp doc,rev.7r26/2018 Title 5 official Inspection Form:Subsurface Sewage Disposal system-Page 6 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Old Town Road Property Address Jeanne Macdonald Owner Owners Name information is Hyannis Ma 02601 10/15/2020 required for every y -• page. Cityfrown state Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 3 Number of bedrooms(actual): 3 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330 gpd Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? ❑ Yes ® No If yes, discharges to: Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes 0 No information in this report.) Laundry system inspected? ❑ Yes 0 No Seasonal use? ❑ Yes 0 No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Daent te _ i5insp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 18 r Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Old Town Road Property Address Jeanne Macdonald Owner Owner's Name information is Hyannis Ma 02601 10/1512020 required for every page. CitYfTown State Zip Code Date of Inspection D. System Information (cont.) 2. 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 Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: ftup doc•rev.7rAw18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 18 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Old Town Road Property Address Jeanne Macdonald Owner Owner's Name information is required for every Hyannis Ma 02601 10/15/2020 page. Citylrown state Zip Code Date of Inspection D. System Information (cont.) 4. 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): Approximate age of all components, date installed (if known)and source of information: system installed 3/1/2002 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: fee 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.): Joints in good condition, no leakage, vented through roof. i t5insp.doc•rev.7/26r2D18 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Old Town Road Property Address Jeanne Macdonald Owner Owner's Name information is Hyannis Ma 02601 10/15/2020 required for every -- page. Citylrown State Zip Code Date of Inspection D. System Information (cost.) 6. Septic Tank(locate on site plan): 2 Depth below grade: 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 I 1500 gallons Dimensions: 511 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 7" Distance from bottom of scum to bottom of outlet tee or baffle 10" Opened covers and took How were dimensions determined? measurements Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tank does not need to be cleaned now but should be done soon and again every 2 years for proper maintenance. water level was even with outlet, tank was not leaking and was structurally sound. Access covers are on risers 15msp.doc•ray.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Old Town Road Property Address Jeanne Macdonald _ Owner Owner's Name information is Hyannis Ma 02601 10/15/2020 required for every y page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) 7. 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 Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): f - i 8. 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 t5msp.doc•rev.7262018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Old Town Road Property Address Jeanne Macdonald Owner Owner's Name information is required for every y Hyannis Ma 02601 10/15/2020 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last um in : P P 9 Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 9. Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 il 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.): Distribution box was level and in good condition with no rot. Water level was even with outlet invert with no signs of past backup. t5insp:doc•rev.7l26MI8 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Old Town Road Property Address Jeanne Macdonald _ Owner Owner's Name information is Hyannis Ma 02601 10/15/2020 \ required for every — — — page. Cityrrown State Zip Code Date of inspection D. System Information (cont.) 10. 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. 11. Soil Absorption System(SAS)(locate on site plan, excavation not required): If SAS not located, explain why: Type: ❑ leaching pits number: ® leaching chambers number: 2x500 gal ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: -- ❑ innovative/altemative system Type/name of technology: t5insp.doc.rev.M2612018 Title 5 Official Inspection form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts lTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Old Town Road Property Address Jeanne Macdonald Owner Owner's Name information is Hyannis Ma 02601 10/15/2020 required-for every y page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System(SAS) (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Leachingfacility was video inspected and found with 6"standing water and no signs of past overloading. 12. 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 Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/2612018 Title 5 Official Inspection form:Subseaface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Old Town Road Property Address Jeanne Macdonald Owner Owner's Name information is required for every �H annis Ma 02601 10/15/2020 � page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): i t5insp.doc-rev.MUM 8 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 r Commonwealth of Massachusetts -�- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments a' 86 Old Town Road Property Address Jeanne Macdonald Owner Owner's Name information is Hyannis Ma 02601 10/15/2020 required for every y _._.. page. Cityfrown state Zip Code Date of Inspection D. System Information (cont.) 14. 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 v � i A ( 3 13 t 3z L( ,AZ 2 v V Z A3 Z 9 �3 Z� GY 31 `i6 t5irup.doc rev.9l26M18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 18 I , Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 85 Old Town Road _ Property Address Jeanne Macdonald Owner Owner's Name information is required for every H annis Ma 02601 10/15/2020 y page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15..Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high round water: 12'+ p 9 9 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: Groundwater was established by accessing town of Barnstable groundwater contour maps. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc-rev.7282018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 f Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 85 Old Town Road Property Address Jeanne Macdonald Owner Owner's Name information is required for every Hyannis Ma 02601 10/15/2020 page. Cityrrown State Zip Code 0 Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B. Certification: Signed & Dated and 1, 2, 3, or 4 checked ® C. inspection Summary: 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5ino.doc•rev.7f2612018 Tide 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 18 of 18 i ovu/v COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 1W David B.Mason,R.S,Certified Title V Inspector,508-833-2177 ASSESSORS MAP NO: PARCEL NO: TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 85 Old Town Road,Hyannis,MA Owner's Name: Gloria Engelsen Owner's Address: Same Date of Inspection: December 19, 2008 I 5i Name of Inspector: (please print)David B.Mason [' I Company Name:—N.A. Mailing Address: 4 Glacier Path East Sandwich,MA 02537 Telephone Number: 508-833-2177 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: _ Passes _X Conditionally Passes Needs Further Evaluation by the Local Approving Authority c�@ Fails Inspector's Signatu Date: i Z ` -00 g Zm The system inspector shall submit a copy of this inspection report to the Approving Authority oad of Heal or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow,of 1 W,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate region.I office o�the r-- DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,a 1 d the approving authority. Notes and Comments: Tank should be pumped as a matter of maintenance. The information as identified represents only the condition of the system on December 19,2008 at 7:30 AM. The leaching system is designed for 3 bedrooms,but the dwelling is 4 bedrooms. The Barnstable Assessors records confirm the 4 bedroom status. One f�(1)additional chamber and 4' stone. ****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 1 Q v Page 2of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 85 Old Town Road,Hyannis,MA Owner's Name: Gloria Engelsen Date of Inspection: December 19,2008 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: Parking area should be defined to prevent parking on septic tank and pump chamber. B. System Conditionally Passes: _X_ 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. THE LEACHING IS NOT DESIGNED TO ACCOMMODATE THE NUMBER OF BEDROOMS. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. _N_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. ND explain: _N_ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: _N The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS Title 5 Inspection Form 6/15/2000 2 Page 3 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 85 Old Town Road,Hyannis,MA Owner's Name: Gloria Engelsen Date of Inspection: December 19,2008 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 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title 5 Inspection Form 6/15/2000 3 Page 4 of 11 PART A CERTIFICATION(continued) Property Address: 85 Old Town Road,Hyannis,MA Owner's Name: Gloria Engelsen Date of Inspection: December 19,2008 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _X_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _NA_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool NA_ Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow —X_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _X_ Any portion of the SAS,cesspool or privy is below high ground water elevation. —X Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 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 privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal 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.] NO_(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must 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 systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system 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. OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title 5 Inspection Form 6/15/2000 4 Page 5 of 11 PART B CHECKLIST Property Address: 85 Old Town Road,Hyannis,MA Owner's Name: Gloria Engelsen Date of Inspection: December 19,2008 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No _X_ _ Pumping information was provided by the owner,occupant,or Board of Health _X_ Were any of the system components pumped out in the previous two weeks? _X _ Has the system received normal flows in the previous two week period? _X_ Have large volumes of water been introduced to the system recently or as part of this inspection? _X _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) _X _ Was the facility or dwelling inspected for signs of sewage back up? _X_ _ Was the site inspected for signs of break out? _X _ Were all system components,excluding the SAS,located on site?(INCLUDING THE SAS) _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)] OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title 5 Inspection Form 6/15/2000 5 Page 6 of 11 PART C SYSTEM INFORMATION Property Address: 85 Old Town Road,Hyannis,MA Owner's Name: Gloria Engelsen Date of Inspection: December 19,2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3 Number of bedrooms(actual):4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 440 Number of current residents: Does residence have a garbage grinder(yes or no): (Not Allowed) Is laundry on a separate sewage system(yes or no):NO [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):No Water meter readings,if available(last 2 years usage(gpd)): 2006: 173,250 2007: 129,000 Sump pump(yes or no):NO Last date of occupancy:Unknown COMMERCIALANDUSTRIAL Type of establishment:_Food Service Design flow(based on 310 CMR 15.203): 330 gpd Basis of design flow(seats/persons/sgft,etc.): Take out-No seating_ 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: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:Barnstable Board of Health Was system pumped as part of the inspection(yes or no):NO If yes,volume pumped:_gallons--How was quantity pumped determined? Reason for pumping:Maintenance pumping conducted after inspection TYPE OF SYSTEM _X 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):With pump chamber Approximate age of all components,date installed(if known)and source of information: Installed 03/01/2002 Were sewage odors detected when arriving at the site(yes or no):NO OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title 5 Inspection Form 6/15/2000 6 Page 7 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 85 Old Town Road,Hyannis,MA Owner's Name: Gloria Engelsen Date of Inspection: December 19,2008 BUILDING SEWER(locate on site plan) Depth below grade:Approx.34 Inches Materials of construction:_cast iron _X_40 PVC_other(explain): Distance from private water supply well or suction line:_NA Comments(on condition of joints,venting,evidence of leakage,etc.): Appears in good condition. SEPTIC TANK: N.A.(locate on site plan) Depth below grade: 6 Inches to riser Material of construction:_X_concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: Typical 1500 gal. Sludge depth:4 inches Distance from top of sludge to bottom of outlet tee or baffle: 28inches Scum thickness:variable 0 inches to 6 inches Distance from top of scum to top of outlet tee or baffle: 0 inches Distance from bottom of scum to bottom of outlet tee or baffle:Not applicable no scum at outlet tee How were dimensions determined: actual measurements Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)inlet tee is PVC.Outlet tee is PVC and appears in good condition. No evidence of leakage. Structure of tank appears adequate. Effluent level with outlet tee. Maintenance pumping is required. GREASE TRAP: N.A. Depth below grade:_ Material of construction:_concrete_metal_fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels , as related to outlet invert,evidence of leakage,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 7 Title 5 Inspection Form 6/15/2000 Page 8 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 85 Old Town Road,Hyannis,MA Owner's Name: Gloria Engelsen Date of Inspection: December 19,2008 TIGHT or HOLDING TANK: N.A._(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX:_YES_(if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Level with outlet invert Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.): There is no indication of soil infiltration that should be cleaned out,dbox is in good condition.Dbox is approx.28 inches below grade.2 outlets which are level. PUMP CHAMBER:,(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM 8 Title 5 Inspection Form 6/15/2000 Page 9 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 146 Rosary Lane,Hyannis,MA Owner:Johnson Date of Inspection: May 9,2008 SOIL ABSORPTION SYSTEM(SAS):_X_(locate on site plan,excavation not required) If SAS not located explain why: Type leaching pits,number: _X_leaching chambers,number:—2_5'x8'precast with 4' stone around _leaching galleries,number: leaching trenches,number, length: _leaching fields,number,dimensions_ overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.): leaching is 32 inches below grade. Riser is present.Chambers are an H 10 rate pit. No indication of ponding nor increase growth of vegetation. Probing did not indicate damp soil. Leaching is not sufficiently designed for the existing 4 bedrooms. CESSPOOLS:_NA_(cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N.A._(locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Title 5 Inspection Form 6/15/2000 9 Page 10 of 11 PART C SYSTEM INFORMATION(continued) Property Address: 85 Old Town Road,Hyannis,MA Owner's Name: Gloria Engelsen Date of Inspection: December 19,2008 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. F Front O P-1 F 1 Septic Tank Al 17' B 1 33' D-Box A2 28'-10" B2 30' Leaching A3 42' B3 29' Title 5 Inspection Form 6/15/2000 10 Page 11 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 146 Rosary Lane,Hyannis,MA Owner:Johnson Date of Inspection: May 9,2008 SITE EXAM Slope Surface water Check cellar (crawl space) Shallow wells Estimated depth to ground water_20_feet Please indicate(check)all methods used to determine the high ground water elevation: _X_Obtained from system design plans on record-If checked,date of design plan reviewed: _X_Observed site(abutting property/observation hole within 150 feet of SAS) _X_Checked with local Board of Health-explain:Recent Test Holes, Existing engineer records with BOH _X_Checked with local excavators,installers-(attach documentation) Accessed USGS database-explain: You must describe how you established the high ground water elevation: Utilized existing site design information on file with the Board of Health. Additionally,existing site and abutting site topography does not indicate ground water to be within 4 feet of bottom of leaching facility. Test holes in the area on file do not indicate ground water within 20 feet of grade. Title 5 Inspection Form 6/15/2000 11 - TOWN OF BARNSTABLE LOCATION S (nk:zl -T0-Wf) - ACE--#— VILLAGE Vj< n 25fi ASSESSOR'S MAP & LOT —*v7I INSTAL"LER'S-NAM-E& PHONE NO. SEPTIC TANK CAPACITY l LEACHING FACILITY:(type) (size) NO. OF BEDROOMS PRIVATE WELL OR UBLIC WATE BUILDER OR OWNER DATE-ER'btlT-ISSif ED: DATE CO? PI:MNeE-ISS°U-ED VA-MA-1Ir£-RA-N-TE —Y=es.. No j__., t � 4 ,.� �• � � ✓...., t4 � � �' sy p G/p ��. �!�% J �� ,- � V .� �' � ^ _� t TOWN OF BARNSTABLE � LOCATION $ O%J SEWAGE #�00 VILLAGE A/ 64,.-.A S ' ASSESSOR'S MAP & LOT 2b `0-7 INSTALLER'S NAME&PHONE NO. X;7�7 SEPTIC TANK CAPACITY LEACHING FACILITY: (type).Z S. e,za fr'ba Ply 1 (size) 13 S- NO. OF BEDROOMS BUILDER OR OWNER J L-v .C, A PERMITDATE: C -,;-S - a d COMPLIANCE DATE: �- Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) Feet Edge of Wetland and Leaching Facility (If any wetlands exist within 300 feet of leaching facility) Feet Furnished by �---- t y,r . 1! A ti � � �� .. .. I �� cf r r f�� 4 D A' 1 4 c'` •/ � ' �.' °Y..fit'.. G� �u V �:r�:,�"6 I �' �� , , � � . * `F.< _ `�) ` '�'�_ `\ l Fee$5 0 THE COMMONWEALTH OF MASSACHUSETTS er Entered in computer: 11�1 Yes PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS 01pplication for Migogal *proem Congtruction Permit Application for a Permit to Construct( )Repair( X Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 85 Old Town Rd. , Hyannis Sally Lucas Assessor's Map/Parcel 7,6 E CJ Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P O Box 1089, Centerville Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sand Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system con— sisting of a 1 , 500 gal. tank, D-box and 2 precast leach chambers with stone all around. Date last inspected: Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boar of He lth. Signe (l Date " Application Approved by _4��Date Application Disapproved 0 the following reasons y Permit No._ f Date Issued No. ow Fee$50 v r ►�„� THE COMMONWEALTH OF MASSACHUSETTS. `lr-.11teAld°in computer: h��es w PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS - 01ppfication for Mgaar *pgtem Construction Permit Application for a Permit to Construct( )Repair( } Upgrade( )Abandon( ) ❑Complete System ❑Individual Components Location Address or Lot No. Owner's Name,Address and Tel.No. 85 Old Town Rd. , Hyannis Sally Lucas Assessor's Map/Parcel Z G Q—7 / Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No. Wm. E. Robinson Septic Service P 0 Box 1089, Centerville r Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow gallons per day. Calculated daily flow gallons. Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Sandr Nature of Repairs or Alterations(Answer when applicable) Title-5 septic system con— sisting of a 1 , 500 gal. tank, D-box and 2 precast leach chambers with stone a ai�oun . t Date last inspected: s Agreement: The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi- cate of Compliance has been issued by this Boar of Hea th. Signed y / Date G ° (5 / Application Approved by a J Date Application Disapproved fo the following reasons ZT Permit No. ;r eyl, ' Date Issued THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Lucas (tertificate of (Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal System Constructed( )Repaired( X)Upgraded Abandoned( )by Wm. E. Robinson Septic Service at 85 Old Town Rd. , Hyannis S has been construe ed in accordance with the provisions of Title 5 and the for Disposal System Construction Pe (@'--'V/"" V dated Installer Wm. E. Robinson Sr. Designer r The issuance of this permit shall not be construed as a guarantee that the sys�m will,ft�nction as de�si ned.r Date.` 0 Inspector ="Cp V a No. o .ram"` �T ' -- fee-$50 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS Lucas 'Wi5po-5al *pttem (Construction Permit Permission is hereby granted to Construct( )Repair( Upgrade( )Abandon( ) System located at 85 Old Town Rd. , Hyannis and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to comply with Title 5 and he following local provisions or special conditions. Provided:Construction us a co 1 ted within three years of the date of i pe . it. Date: Approved by 1 ( y ` V 1161" �NOTWIEz This Fortm Is To Be Used For the Repair Of Failed Septic Systems Only. Cam_1'IIiiC.i►'IYON OF SKI AIdD aPF�..ICA7�i ItOR A DISPOSAL WORKS CONTMUCUON PIL�RHIP�'�VVtTHOUi'DMGNM MANS) William E_ Robinson,S%ftebv cenify dm the application fir disposal works coamt uc mou Qezt m wed by me damd ��-�$L t� .Ong twe 4ropaZY located at 85 Old Town Rd. , Hyannis meets all of the foliawutg cntem • Tbt failed sysmmjscom=cmdmammftmddweUmg=jY There art:mcummarmi or business wish toe dadhvg. Tlie t is classified as CLASS i and tLe peToW�raue is tZss uiau Ar egltal lv�minuues pa itic!►. There c no v�100 fm of dte pn*owd squc k-tacm — • Tbui tm pavac wdb ws�17-0 ice a Ybc pmposcd s[ptac swat There an iumcme iu&m a� iu lave pmposcd There we no variances n upwsmd at aeedod_ The of the kmdmmR bmbtY will am tm kmmd less dun five fi [aba.th. immo om adjmcd gramudmmm mmW e3evatmm fA&pu the gmundvvater tabu quag the Fnmptor ombW when ! if the 1?LS.wilt be kcmd weth 250 ka of avy vepmad Weftuds.the boom of the proposed i=chiag bcfty wiR W be kaKcd less than fou W=t 1a)foci above the matnmm adjm" Vumndw=crubkdcvadum, �) TOP of Gttitmd Stitfaoe t�S GIS uaiom�u) _ Bi G.W.F.Mration +lk MAX 160 G W _ DIFFERENCE BUFWEE14 9 aed S SIGNED: DATE: (Skcu:h P MPS PbB Of SYSM on bml]_ ! r t i! �.� .�..-�C F v ' - I ' o c o � T� � 1 � )� Y^ ' t `' I L f ( TOWN OF BARNSTABLE LOCATION d !au-) SEWAGE #o_LQ VILLAGE Zy' S ASSESSOR'S MAP & LOT INSTALLER'S NAME&PHONE NO. __2n SEPTIC TANK CAPACITY LEACHING FACILITY: (type)._ P^4c Pl; 1 Z (size) NO. OF BEDROOMS BUILDER OR OWNER PERMIT DATE: P COMPLIANCE DATE: "/"e 2— Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet Private Water Supply Well and Leaching Facility (If any wells exist- on site or within 200,feet of leaching facility) Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of leaching facility) Feet Furnished by .01 r I d . s f ----------------- ------------ II• ' ;ail ' I, _ �; IT" , N: '7r ilk r, : -� v - i Ti f I ; 1 i j I C' t �I dIN't'i@g i 4 � a J I � i 1 I � a t i 1 d a J a i I