Loading...
HomeMy WebLinkAbout0039 PEACOCK DRIVE - Health 39 Peacock Drive - Hyannis A= 269 - 201 a 0 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 39 Peacock Drive Property Address Paul Fazio Owner Owner's Name information is required for every West Hyannisport MA 02601: 7/31/14 fi page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: r key to move your cursor-do not Brett Hickey use the return Name of Inspector s key. B&B Excavation Company Name 14 Teaberry Lane Company Address Sandwich Ma. 02644 City/Town State Zip Code (508)477-0653 S113747 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.Basses ❑ Fails ❑ Needs.F rther Evaluation by the Local Approving Authority 7/31/14 Inspector's. ' nature 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. CsZ o f 12 t5ins•3113 - - Title 5 Official InspectionWor,, bs,,IaeSewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 39 Peacock Drive Property Address Paul Fazio Owner Owner's Name information is p required for every y West H annis ort , MA 02601 7/31/14 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® .I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 31.0 CMR 15.304 exist;Any failure criteria not evaluated are ` indicated below.. Comments: t t 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):. ' II i t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 r Commonwealth of Massachusetts Title 5-Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 39 Peacock Drive Property Address Paul Fazio Owner Owner's Name information ie West H annis ort MA 02601 7/31/14 required for every y p page. Cityrrown State Zip Code Date of Inspection B. Certification. (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes.(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass.inspection.if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N- ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced. ❑ Y • ❑:.N ❑ ND (Explain.below): El 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•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts` Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form Not for Voluntary Assessments M 39 Peacock Drive Property Address, Paul Fazio Owner Owner's Name information is required for every West Hy p annis ort MA 02601 7/31/14 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and.environment: ❑ The system has a septic tank and soil absorption system(SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ .The system has a septic tank and SAS.and the SAS is within 50 feet of a private water supply well. ❑ The system.has a septic tank and.SAS and the SAS is.less than 100 feet but 50 feet or more from a private water supply well**. Method used to.determine distance: . **This system passes if the well water analysis,.performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to.this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due.to overloaded or ® clogged.SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters ® due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution.box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/day flow t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -^Not for Voluntary Assessments M 39 Peacock Drive Property Address Paul Fazio- Owner Owner's Name information is . required for every West Hyannisport ' MA 02601 7/31/14 page. CitylTown 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 El ® tributary to a surface watersupply. - ❑ ® 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,forfecal 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: El ® The system fails. I-have determined that one or more of the above failure criteria exist as described 1n 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 El ❑ the system is within 200 feet of a tributary,to a surface drinking water supply El 1-1 Area system is located in a nitrogen sensitive area.(Interim Wellhead Protection f 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-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 39 Peacock Drive Property Address Paul Fazio Owner Owner's Name information is n West H anis ort MA 02601 7/31/14 required for every y P page. CityFrown 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) . IM ❑ Was the facility or dwelling inspected,for signs of sewage back up? Z. ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the.SAS, located on site? . ® ❑ Were the septic tankmanholes uncovered, opened,and the interior of the tank inspected for the condition of the.baffles or tees, material of construction, 3 dimensions, depth of liquid., depth of sludge and depth of scum? Was the facility owner(and occupants if different from owner.)provided with El, f 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): 3 Number of bedrooms (actual): 2 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330 M t5ins•3/13 Title 5 Official.nspection 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 39 Peacock Drive Property Address Paul Fazio Owner Owner's Name ` information is required for every West HY P annis ort MA 02601 7/31/14 _ page. Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection El Yes. ® No information in this report.) Laundry system inspected? p ® Yes ® No Seasonal use? ❑ Yes ® No / Water meter readings, if available (last 2 years usage (gpd)): Detail Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No I Industrial waste holding tank present? ❑ Yes ❑ No I 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 4 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Forme Not for Voluntary Assessments ,M 39 Peacock Drive Property Address Paul Fazio Owner Owner's Name information is West H annis ort MA 02601 7/31/14 required for every Y P page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date a Other(describe.below): 'General Information Pumping Records: Source of information: M Was system pumped as part of the inspection?.• ❑ Yes ® No If yes, volume pumped: gallons How was YP pumped umdetermined?ed q 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): z t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i. Commonwealth of(Massachusetts Title 5 Official Inspection Form Subsurface Sewage (Disposal System Form Not for Voluntary Assessments �M 39 Peacock Drive 5 Property Address Paul Fazio Owner Owner's Name information is p required for every y West H annis ort MA 02601 7/31/14 page. City/Town State Zip Code Date of Inspection D. System Information (cost.) Approximate age of all components, date installed (if known) and source of information: . 1984 Were sewage,odors detected when arriving:at the site?. ❑ Yes ® No Building Sewer(locate on site plan): 3' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): k Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): At time of inspection building sewer a ppeared:to,be in good working order. No sign of leakage. 4 .. .. - .. Septic Tank(locate on site,plan): Depth below grade: feet Material of construction: ' ® [-] metal .concreteEl fiberglass ❑ polyethylene ❑ other(explain) s ' If tank is metal,list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No 1000 gal. Dimensions: e 8 Sludge depth: t5ins•W 3 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 39 Peacock Drive Property Address Paul Fazio Owner Owner's Name information is required for every West Hy p annis ort MA 02601 7/31/14 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 28 Scum thickness 6 Distance from top of scum to top of outlet tee or baffle 3 Distance from bottom of scum to bottom of outlet tee or baffle $ How were dimensions determined? scour stick } Comments (on pumping recommendations,inlet and outlet.tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): At time of inspection septic tank appeared to be in working order: Tees present. No sign of back=up. t } 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 39 Peacock Drive Property Address Paul Fazio Owner Owner's Name information is West H annis ort MA 02601: 7/31/14 required for every y P . page. City/Town State Zip Code Date of Inspection D. System Information (Pont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): ; r Tight or Holding Tank(tank must be pumped;at time of inspection) (locate on site plan): Depth below grade: t t Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): t Dimensions: q Capacity: 4 gallons ` Design Flow: gallons per day t Alarm present: ❑ 'Yes ❑ No t Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): k Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No 4 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 39 Peacock Drive Property Address Paul Fazio Owner Owner's Name information is required for every West HY p annis ort MA 02601 7/31/14 page. City/Town 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.):. At time of inspection d-box appears to in.working order. No sign of deterioration or carryover. Pump Chamber(locate on site plan): Pumps in working order. ❑ Yes ❑ No* Alarms.in working:order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.)` 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: t � t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 ! f Commonwealth of Massachusetts Title 5 Official Inspection Form . Subsurface Sewage Disposal System Form Not for Voluntary Assessments t M. 39 Peacock Drive Property Address Paul Fazio Owner Owner's Name information is required for every West HY p annis ort MA .02601:. 7/31/14 - page. Citylrown State :Zip Code Date of Inspection D. System Information (cont.) t Type: ® leaching pits 4,number: 6'X6' EJ leaching chambers number.: ❑ leaching galleries number: ❑ leaching trenches number, length: t ❑ 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.): At time of inspection leaching appears to be in working order. No,sign of hydraulic failure.Water level was 3' below invert at time of inspection. t 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 F Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments t y 39 Peacock Drive _ Property Address Paul Fazio Owner Owner's Name information is p required for every y West H annis ort MA :02601 7/31/14 page. City/Town State Zip Code Date of Inspection II 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.): f t5ins•3M Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 F commonwealth-of Massachusetts Title 5 Official Inspection Form Subsurface:.Sewage Disposal System Form-Not for Voluntary Assessments . 39 Peacock`Drive Property Address . Paul Fazio Owner Owner's Name information is MA 02601 7/31114 required for every West Hyanriisp6rt page. City/Town 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 within100 feet. Locate where public water supply enters,the building. Check one of the.boxes below.- hand.=sketch in the area.below E drawing attached separately a . - a aa' O _ x7 tcl E 4 t5ins•3/13 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. 39 Peacock Drive Property Address Paul Fazio Owner Owner's Name information is required for every West HY P annis ort MA 02601 7/31/14 page. Cityfrown state Zip Code Date of Inspection D. System Information (Pont.) Site Exam: ' ® Check Slope ® Surface water r ® Check cellar _ ® Shallow wells Estimated depth to high ground water: >12" ( '' feet } Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans,on record . .12/18/84 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 with1ocal excavators, installers - (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground`water elevation: Plan on file 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 39 Peacock Drive Property Address Paul Fazio Owner Owner's Name information is r equired for every y P West H annis ort MA 02601 7/31/14 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 drawnon page 15 or attached in separate file 4 t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 a 4 K:. Commonwealth of Massachusetts Title 5 Official Inspection Form a p as Not for Voluntary Assessments •4^M Subsurface Sewage Disposal System Form Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/15/2000. Inspection forms may not be altered'in any way. A. Certification 1. Property Information: , 39 Peacock Dr. au Property Address Ian Evans Owner's Name same Owner's Address West Hyannisport MA 02601 City/Town _ State Zip Code 7/23/07' Date of Inspection: Date 2. Inspector: Matthew L. Childs a ' Name of Inspector # same Company Name " wv 4 Orchid Ln. ` Company Address v� W. Yarmouth. MA 02673? : City/Town,.. State Zip Code 508-9891479 Telephone Number Certification Statement: I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of 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 Ito ❑ Needs Further Evaluation by the Local Approving Authority 7/23/07 Inspector's Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the.inspector and the system owner shall submit the ' report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments iG^M Subsurface Sewage Disposal System Form • A. Certification (cont.) 39 Peacock Dr. «' ' Property Address West Hyannisport MA . 02601 City/Town State Zip Code Ian Evans 7/23/07 r Owner's Name Date of Inspection 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: . passes y B) System Conditionally Passes: ❑ One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. . Answer yes, no or not determined (Y, N, ND) in the ❑lfor the following statements. If"not determined," please explain. F ❑ 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/A Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16. 4 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments ^M Subsurface Sewage Disposal System Form A. Certification (cont.) 39 Peacock Dr. Property Address West Hyannisport MA 02601 City/Town State Zip Code Ian Evans 7/23/07 Owner's Name Date of Inspection B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken„settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s) are replaced ❑ obstruction is removed ❑ distribution box is leveled or replaced ND Explain: N/A ❑ 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: N/A 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 I 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 Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts Title 5 Official -inspection Form r Not for Voluntary Assessments Subsurface Sewage Disposal System Form /4^M A. Certification (cont.) 39 Peacock Dr. Property Address ,West Hyannisport MA 02601 City/Town State " ' Zip Code Ian Evans 7/23/07 Owner's Name Date of Inspection C) Further Evaluation is Required by the Board of Health (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: fi ❑, 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 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. y f ElThe system has a septic tank and SAS and the SAS is Y` less than 1_00 feet but 50 feet or more from a private water supply well". Method used to determine distance: N/A ;` y *' 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: N/A x Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 'Commonwealth of Massachusetts Title 5 Official' Insp ection Form - Not for Voluntary Assessments Subsurface Sewage"Disposal System Form A. Certification (cost.) 39 Peacock Dr. Property Address West Hyannisport MA 02601 City/Town '° State ZipCode Ian Evans 7/23/07 = fi Owner's Name Date of Inspection. D)System Failure Criteria Applicable to All Systems: You must indicate"Yes"-or"No"to each of.the,following for all inspections: Yes NO" 1 ` ❑ ® Backup of sewage into'facilityor system component due to overloaded or,clogged SAS or cesspool . ❑ ® Discharge or ponding.of effluent to the surface of the ground or surface waters w 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 than6°' below invert or available volume is less than '/z'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. El ® Any portion of cesspool orpriVy is within'l00 feet of a surface water su pplyr or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy.is within a Zone 1 of a public well. ❑ Z Any portion of a cesspool or privy is within.50 feet of a private water supply well. ❑ z 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.] a 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. Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of.16 Commonwealth of Massachusetts W Title 5 Official ection Form Ins . p Not for Voluntary Assessments Subsurface Sewage Disposal System Form A. Certification (cont.) 39 Peacock Dr. Property Address West Hyannisport MA 02601 City/Town State Zip Code Ian Evans 7/23/07 Owner's Name Date of Inspection 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 ❑ El 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. I Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M B. Checklist 39 Peacock Dr. Property Address West Hyannisport MA 02601 City/Town • State Zip Code Ian Evans _ 7/23/07 Owner's Name Date of Inspection 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 thesystem received normal flows in the previous two week period? El ® 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 inthe 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)] Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 Commonwealth of Massachusetts Title ,5 Official ln* spdct'ion Form ' Not for Voluntary Assessments ' Subsurface Sewage Disposal System Form C. System Information 39 Peacock Dr. Property Address . West Hyannisport MA 'f 02601 City/Town , State Zip Code Ian Evans 7/23/07 Owner's Name Date of Inspection 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. 2 Number of current residents:' Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No- Laundry system inspected? ❑ Yes ® No Seasonal use? ❑ Yes ® No Water meter readings, if available last 2 ears usage (gpd))-. N/A 9 ( Y 9 _ Sump pump? ❑ Yes ®''No • r ;, Last date of occupancy: current cute Commercial/Industrial Flow Conditions: Type of Establishment: N/A Design flow(based on 310 CMR 15.203): N/A' Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): N/A ; Grease trap present? ❑ Yes ❑» No. Industrial waste holding'tank present? ❑ Yes. ❑ No Non-sanitary waste discharged to the-Title 5 system? ❑ Yes r❑ No Water meter readings, if available: , N/A Last date of occupancy/use: N/A Date Other(describe): N/A. Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 - b Commonwealth of Massachusetts Title 5 Official ' Inspection Form w Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 39 Peacock Dr. Property Address West Hyannisport MA 02601 City/Town• State Zip Code Ian Evans 7/23/07 Owner's Name Date of Inspection, General Information Pumping Records: owner Source of information: Was system pumped as part of the inspection? ® .Yes ❑ :No 1000 If yes, volume;pumped: gallons How was quantity pumped determined? Sight on truck Reason for pumping: maintainance , Type of System: ® Septic tank, distribution box, soil absorption system, ❑ Single cesspool ❑ Overflow cesspool F ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) t ❑ 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) andsource of information: N/A . Were sewage odors detected when arriving at the site? ❑ Yes ® No k Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9'of 16 Commonwealth of Massachusetts 0% Title 5 Official- Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form •6+y C. System Information (cont.)' -e 39 Peacock Dr. ` Property Address West Hyannisport MA 02601 . City/Town State Zip,Code Ian Evans 7/23/07 Owner's Name Date of Inspection Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ❑ cast iron ®40 PVC ❑ other(explain): Distance from-private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): All in good working order at time of inspection. Septic Tank(locate on site plan): Depth below grade: 1.5'. 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 ❑ Yes ❑ No certificate) Dimensions:.. 8'x5'x5'outside 1000 gal. Sludge depth: 4, Distance from top of sludge to bottom of outlet tee or baffle 3.5' Scum thickness 4 Distance from top of scum to top of outlet tee or baffle 3' Distance from bottom of scum to bottom of outlet tee or baffle .8' How were dimensions determined? sludge judge Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 Commonwealth`of Massachusetts Title 5 Official Inspection Form. ' Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information cont. 39 Peacock Dr. Property Address West Hyannisport MA 02601 Cityrrown State Zip Code Ian Evans 7/23/07 Owner's Name Date of Inspection 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 shows no signs of leakage and was maintained properly at time of inspection Grease Trap (locate on site plan): Depth below grade: N/A feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ,❑ other(explain): N/A Dimensions: N/A Scum thickness N/A Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Date of last pumping: N/A 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.): N/A Tight or Holding Tank (tank must be pumped at time,of inspection) (locate on site plan): Depth below grade: N/A Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene +❑ other(explain): ` N/A I Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts ` Title 5' Official Inspection Form l; Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 39 Peacock Dr. Property Address West.Hyannisport MA 02601 Citylrown State Zip Code Ian Evans 7/23/07 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: N/A • - Capacity: N/Agallons Design Flow: N/Agallons per day Alarm present: ❑ Yes ❑ No Alarm level: N/A Alarm in working order: ❑ Yes❑ No Date of last pumping: N/A Date Comments(condition of alarm and float switches, etc.): N/A Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0.0' 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.): D-box shows no solids carryover or leakage at time of inspection. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 f Commonwealth of Massachusetts Title 5 Official 'inspection Form Not for Voluntary`Assessments Subsurface Sewage Disposal System Form C. System Information (cont: ) 39 Peacock Dr. Property Address West Hyannisport MA 02601 City/Town State Zip Code Ian Evans 7/23/07 Owner's Name Date of Inspection Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS) (locate on site plan,excavation not required): If SAS not located,`explain why: . A Type: ® leaching'pits number: 1 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields :number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system ' V Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): - t" 1 6'x6' pit was dry showing no signs of hydraulic failure at time of inspection. Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 'Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal'System Form C. System Information (cost.) , 39 Peacock Dr. Property Address West H_yannisport MA 02601 City/Town State Zip Code Ian Evans 7/23/07 Owner's Name Date of Inspection Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration N/A Depth—top of liquid to inlet invert N/A Depth of solids layer N/A ,Depth of scum layer N/A Dimensions of cesspool N/A Materials of construction N/A Indication of groundwater inflow ❑ Yes ❑ No Comments (note condition"of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): N/A t Privy (locate on site plan): Materials of construction: N/A Dimensions N/A Depth of solids N/A Comments (note condition,of soil, signs of hydraulic failure,'level of ponding, condition of vegetation,-, etc.): N/A S Evans.doc• 11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 -'Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments " Subsurface Sewage Disposal System Form �M C. System Information (cont.) 39 Peacock Dr. Property Address West Hyannisport MA 02601 City/Town State Zip Code Ian Evans 7/23/07 Owner's Name. 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. �acock Drive, /S C #39 A-1-26' B-1-15' A-2-32' B-2-22' A-3-40' B-3-27' O A-4-30' B-4-38' Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 15 of 16 Commonwealth of Massachusetts H Title 5 Official Inspection Form F Not for Voluntary Assessments Subsurface.Sewage Disposal System Form. C. System Information (cont.)- 39 Peacock Dr. Property Address West H annisp ort MA 02601 Cityrrown State Zip Code Ian Evans 7/23/67 Owner's Name ' Date of Inspection` Site Exam: Slope Surface water Check cellar' Shallow wells Estimated depth to ground water: 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: pate ❑ 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) r ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Hand auger 8' in bottom of dry leach pit and did not encounter groundwater. • Evans.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 I, Town of Barnstable pp IME 1p� Regulatory Services snxxsrnsre: ; Thomas F. Geiler,Director v$ MASS. `0� A)E16 9. Public Health Division Thomas McKean, Director 200 Main Street, Hyannis; MA 02601 Office: 508-862-4644 Fax: 508-790-6304 This septic system inspection report was completed by a private inspector who is certified by the State of Massachusetts, Department of Environmental Protection. Although the Town of Barnstable Health Division received the original/copy of this report;this Division does not warranty the functionality of the septic system in the future nor does this Division agree with any technical observation s and interpretations contained within this report. In addition,by receiving this report the Town of Barnstable Health Division does not automatically approve the number of bedrooms listed within this report. The actual number of bedrooms approved at a particular property would-be listed on the "Disposal Work Construction Permit". If you should have any questions regarding this report, please contact the certified Septic System Inspector who conducted the inspection. I LG" r,,,. n SEWAGE PERMIT NO. VILLAGE nn INSTA LLER' ,, NAME' i ADDRESS Or"sclo B U ILDE R OR -OWN ER / b-ATE PERMIT ISSUED. IM.P-yL I A N C E I S S,U E.D 141. t w , � � � �.. � �� �_ _ � � �� (� � � Q {I / ' a k. f� .� •. ,'', �, � '� _ � ^. No.�.14 .. ....._ Fins.. ........: THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH ............... .TjQ/�. L. ........................................ Apptiration for Dhip iial Workii Tomtrurtion frrutit Application is hereby made for a Permit to Construct or Repair ( ) an Individual Sewage Disposal System at: /'J, �l �/is Poe i / ........ _ ....... .... ... - ..... Location•Address or Lot No. ......... _ 1...................... er Address ---------------------------------------------- ......_... Installer Address // // Y Type of Building Size Lot... JAY.t ........Sq. feet Dwelling—No. of Bedrooms.-...... ...........................Expansion Attic WO) Garbage Grinder (NO) Other—Type of Building 0D 1�i... No. of persons.....2.................. Showers (,2,) — Cafeteria (Vol Q' Other fixtures .......�I Vic..------•-----•--••••-•-•• W Design Flow............. ....................gallons per person per day. Total daily flow..........3.3.0.....................gallons. 0; Septic Tank—Liquid capacity.M.-VO-gallons Length....IP...... Width....4........ Diameter----4--------- Depth.....7—------ Disposal Trench—No....o!_U9�--- Width.................... Total Length.................... Total leaching area...a_4_ ----sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box (},) Dosing tank ) A �/'-' Percolation Test Results Performed by.....�1----4. c.e......���106-61t..... Date..... D .._ ;X......... ,a Test Pit No. l.G. ....minutes per inch Depth of est Pit.../A........... Depth to ground water....-/.�m('�...... Test Pit No. 2................minutes per inch Depth of Test Pit..--................ Depth to ground water........................ A ............................}--•-- Description of Soil mil= i .r-S�l??._Stld ----------------------------------------------•----------------•----- -------------•....-----------•----- -s � �E�-._..- t= ....... c �........-------------•---------•--•----•........:.-........------------------. W ------------------------------------ ME_, .......54_i.1,.•••••••-----•------•••---.--------•--•----•-••----------------•----••----••--•---•••----••---•-------------... 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 TI L U 5 L e State S itary Code— The undersigned further agrees not to place the system in eration until ertifi mplian as been issued by the board of health. igned.: .P /a;e ..... Application Approved BY•---•------ - ........................................................-----------------•--- --._.._l ... .-1`- --�:_.'....-------- D ate Application Disapproved for the following reasons:.................................... .......................... ----------------------------------------------- ....................................•----•--•---•-------......--------.........-•....................................................---•................................................................ s Date PermitNo........................................................ Jssued........................................................ Date Fss..�.,�..................._ THE COMMONWEALTH OF MASSACHUSETTS �. BOARD OF HEALTH .._ .............OF... l,tR'� Tf� Lt� Appliraation for Disposal Works Tonstrnrtiun thrmit Application is hereby made for a Permit to Construct (.A ) or Repair ( ) an Individual Sewage Disposal System at: ' ..Location-Address Vy- or Lot No. __._...• ... .......................................................... --....-----.._.....------•------•---•----•---.._.._..------•--•--•--------.................._...._ Owner Address .................................... . nstaller Address Type of Building Size Lot__Id.....................Sq. feet �-, Dwelling—No. of Bedrooms_______:=r�_______________________________Expansion Attic Q,c Garbage Grinder (/, ) Other—T e of Building 1�� n. t ,/a_•••- a —Type g ____________________ No. of persons_,_.2.................... Showers (.r ) — Cafeteria F(;4/) P4Other fixtures .......Alrl'AJ�............................................................................................................................... W Design Flow............. `_......................gallons per person per day. Total daily flow-------._''__j_!-_.______________._____gallons. WSeptic Tank—Liquid"capacity.�C.2��_gallons Length._.. ....... Width__........... Diameter...I............. Depth_.__r7......... x Disposal Trench—No. a _.._______ Width.................... Total Length... Total.leaching area__ :_l.__!...... ft." Seepage Pit No_____________________ Diameter............._...... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ', ) Dosing tank,( ) '~ Percolation Test Results Performed by...... /..rr�_:. (__ ...____ !!/: �::_:.! _ f`___._. Date.___%.G. .:_..!___ Test Pit No. 1 _-? ______minutes per inch Depth of Test Pit_. �v_________ Depth to ground water_._�t_..>_::_!_..... 44 Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................ a -------•------•-•••-•-----------•-------•-....---•-------------------------------------•-------------......-•----•-------...•----••-•••••-=- ---•-•-- Description of Soil... -- U ------------------•--••---------•-•, _ S -.�•_ �• . 1r A S.4?4` I 1 + .. . V Nature 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 TITLE 5 of the State S itary Code—The undersigned further agrees not to place the system in eration until Certifi of Complia as been issued by the board of health. � r � Signed = '••-----------........................... i ,v,�•r•-- `s � r f r � Date ------- Application Approved B "'. ....... r Date Application Disapproved for the following reasons:................................................................................................................. ..................•-----•--------------------._....--••-----••----•---•-----•----•----•----•----•--......._.__...__...----------------•-----------•-----•--•--------•--------------_._-------------•-_..._ Date PermitNo......................................................... Issued_....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH lh.' .......................OF..... c� :: !.�. .t._c.... Tntifiratr of TompliFanrr THIS IS TO CERTIFY, That the Individual Sewage Disposal System constructed (�',) or Repaired ( ) by........ - /------- ='=r'''-ij----•-- �// � Installer / / / 1 ------------------- at----) r*�T 1,4 jf-// // e- /f' r//J /'/ r /` / ,- - -- 7 has been installed in accordance with the provisions of TITLE 5 of The State Sanitary Code as described in the application for Disposal Works Construction Permit No............................. __________ dated................................................ THE ISSUANCE OF THIS CERTIFICATE SHALL N_0T--BE,C,O TRUE® A GUA NTEE THAT THE SYSTEM WILL FU CT ON SATISFACTORY. DATE.........................---• t�.........•••-•-•--•---•-•••---- Inspector.......... .....• -•- f.. 1 THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH No.......................... FEE:• .................. Disposal Works Tonstrnrtion rrmit Permission is hereby granted.... ....... -=....................___--•--•------------••-----•--•--------••--------------------...................................... to Construct (d4! ) or;Repair ( ) an Individual Sewage Disposal System at No._A-......i......... 1 ! ,,. { Street ,_. ........_;---I— i as shown on the application for Disposal Works ConstructiqLi ermit }�T 7_0______ Dated........ .... .,�_-�_ ' if DATE......... �--•-------------•--•---•--- _-•-•_•• Board of Health FORM 1255 A. M. SULKIN, INC., BOSTON �` 2 � i { h Y. t { _.,+J F ` . A. 4, f U .O .., , _ / d raj. 3 s 0(� tc� 0 .; r dF3 h1A S Tom' �n 1= c SE sa t 20, +. tdo.10951 01 �O Rr �.0�' S' nj �� F"S/ONM q J0 J, LEGEND ,IM45T'INS SPOT ELEVATION Otto ;, �Y CERTIFIED PLOT PLAN tfl*l8HED SPOT ELEVATION t st d �'ViS pE�ll Z-v 7" }I Th€e location of any existing und�ri•ound'sewerage, IN xells,-_ or`,othey uti ities shown on this plan is .approx- xm te:`onl as•'.d„termine'd` from records, and/or'verbal.1 t{ % �%nformation.. The contractor is responsible for''the "� � �verifa.caton of the- existing .locations.,.in the field. SCALE► / ": gyp ', DATE , t�' ; 'IV�°d�VE 'A'ANG Cl�. lAi CLIN'I:. I cERTIFv . THAT THE PROPOSED } T g,� �98 _ + MISTER It�t3I�T�#�EQ J®� NO. BUILDING SHOWN ON THIS PLAN + ` CIVIL . LAND Ir1�.13V CONFORMS TO THE ZONING LAWS � �1 • � � r E ® P{DER id9/ OI` BARNSTAB E 1,AAS t 'Ta2 'PAAI Id STREET CH. By IiYANN S, MASS.' SHEET OF ; ?— 4AA REC. LAND SURVEYOR ,J _ QC tN- lk a NO ul 4 -kit,91 fit} h 3 yob �® � @® _ W ���jp®?' .-1 u �• \ :'; m t, . 044 ® . is a 17 Oyu ® w iko ll V �n a o• o w s �s o \'t V i! Ci 1 . '"� � _ � 'iN - � \ ,� r �.W f7�; �O r•+ �' - ./ TT� .. S°r`^-t°:�� {r`ate. Ln al r �, .��`� � ,.�._M�9 �, ��++AA O�.. 1'�d V _ate_ � •` �� `(yk n�" 5 y3N.'N x�,� •r gam, YyY' ]i�! gyp.. A` r ti ¢ V� 5 yk' •, _mil' �e r e•��, P Y ya fk Vp aj w .� � `(L�`�.'. � � . •.Q � .�•'W ® � � � ��.y'�• �. :�. �`� f'f46j �,�� ��.f1Zl� q� f fif�: cr.