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0089 PONTIAC STREET - Health
89 Pontiac Street Hyannis P A = 269 063001 ti k n I� I' F p i� �i I� ,I TOWN OF BARNSTABLE LOCATION SEWAGE VILLAGE /)��/����`� ASSESSOR'S MAP&PARCEL -2 ®®f INSTALLER'S NAME&PHONE NO. �� �'� 7", s" 07,07 SEPTIC TANK CAPACITYl� C®a-C,01?I—l� LEACHING FACILITY. (type) c,,,yAmPeatP-. (size) X o� NO. OF BEDROOMS 3 OWNER PERMIT DATE: COMPLIANCE DATE: ® � Separation Distance Between the: ® Zir"Ar'na 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 ) A B n- 33 6� i TOWN OF BARNSTABLE q LOCATION U� �N�t e,C— SEWAGE # VILLAGE L�U OWfj IJ ASSESSOR'S MAP&LOT �e�cyo INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY 10QQ ��. LJ:ACHING FACILITY: (type) D t T (size) I O00!�J l4,- , NO OF BEDROOMS BUILDER OR O R ,t Mc)r-J ?EfU9tffDATE: i��w _COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table and Bottom of Leaching Facility ( Feet Private Water Supply Well and Leaching Facility (If any wells exist on site or within 200 feet of leaching facility) t'J ilk Feet Edge of Wetland and Leaching Facility(If any wetlands exist �U /4� Feet Lwithin 300 feet of leaching facility) Furnished by �Z!✓`� rp I � st � v f � TOWN OF BARNSTABLE LQCAT16N .�� ���y�n c � SEWAGE # VILLAG 4 417/S ASSESSOR'S MAP & LOT 269 63 INSTALLER'S NAME&PHONE NO. SEPTIC TANK CAPACITY J.EACHING FACILITY: (type) le 4G'k .12 (size) NO.OF BEDROOMS .3 t � r iJILDER OR OWNER .Jeu c-1 Ayp/'ei./ PERMTr-DATE; J�t/ue' Z/�.l I d S COMPLIANCE DATE: Separation Distance Between the: Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility 4- Feet Private Water Supply Well and Leaching Facility (If any wells exist a J� on site or within 200 feet of leaching facility) / Feet Edge of Wetland and Leaching Facility(If any wetlands exist within 300 feet of l9aching facility) Feet Furnished by m 6v 4Z N I N N N n A r ` Ln Q :ti LO,C•ATION SEWAGE PERMIT NO. VILLAGE -/ / S��h tNSTA LLER'S NAME i pADDRESS v R U I L D E R OR OWNER DATE PERMIT ISSUED DATE COMPLIANCE ISSUED N ff- � 4`' �� -��- - uv No. � Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Yes PU LIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS MY\ applitation for Misposal *pBtem Construction Permit Application for a Permit to Construct Repair U ade Abandon ❑Complete System Individual Components PP ( ) P (�P�' ( ) ( ) P Y Location Address or Lot No. ?./1*1 ��,evTJ�/ Zl_ Owner's Name,Address,and Tel.No.Assessor's Map/Parcel � ` 4 6 -� o J �, /� .79 5:�' JD -d-a I?/,I— Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms Lot Size sq.ft. Garbage Grinder( ) Other Type of Building s�' No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) `s gpd Design flow provided �� gpd Plan Date �� �"'�7 Number of sheets Revision Date Title Size of Septic Tank ��'���� �+'� � Type of S.A.S. Description of Soil JN'+-<r Nature of Repairs or Alterations(Answer when applicable) 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 Certificate of Compliance has been issued by this Board of Health. Q G Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. �1 7 Date Issued No. Fee [)!) THE COMMONWEALTH`OF MASSACHUSETTS Entered in computer: Y✓ PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE, MASSACHUSETTS f � Y ! 2ppIltatI01I for 13ISpOsaY *pstellt CDTCBtrUttlOtl 3Perlttlt Y Application for a Permit to Construct( ) Repair(A100upgrade( ) Abandon( ) . ❑Complete System A Individual Components Location Address or Lot No. V! J%7- Owner's Name,Address,and Tel.No. Assessor's Map/Parcel ,7& 0 6 1,0 O ! 11�y 'r -Z 1 jA 77"LP-, 00 j�4-® �/s Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. III=•. �»;,#. ��o�v� 7 ems' ® r 0,7 Type of Building: Dwelling No.of Bedrooms 13 Lot Size sq.ft. Garbage Grinder( ) ~ Other Type of Building ,d' P P. No.of Persons Showers( ) Cafeteria( ) - Other Fixtures Design Flow(min.required) a 0 gpd Design flow provided 3 J5;_/p gpd Plan Date /� — 9�- .�� Number of sheets /1 Revision Date - Title Size of Septic Tank �'x/pl�1✓' �� a� Type.of S.A.S. G' ejdl' Description of Soil J"kdre Nature of Repairs or Alterations(Answer when applicable) ,A�Er /�1�r�✓(� J ` 1 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 Certificate of Compliance has been issued by this Board of Health. p �y Signed _ Date Application Approved by Date / _ �.� Application Disapproved by Date P fo'r+the following reasons Permit.No. -7 Date Issued �i l -------------------------- ---------_ _-----------------------------------------------: --------------------------------------- TH E COMMONWEALTH OF MASSACHUSETTS F BARNSTABLE,`MASSACHUSETTS , Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( ) Abandoned( )by e%11 .t'G �/C ✓'y 6» at P �01�10,� G J'T has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No.,d V- V 7,-dated 1.2 `9 I Installerc. 77 to�0��/` Designer®,'1/°/�o 46 #bedrooms 3 Approved design`_Mw 3 3U - /fin gpd 1 The issuance of this permit �s•�hyal not be construbd as a guarantee that the system will fictas' degdd ne Inspector i i Date l f. No. y I �( l a Fee j THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION-BARNSTABLE,MASSACHUSETTS Disposal *pstem Construttion permit Permission is hereby granted to Construct( ) Repair(10.1< Upgrade( ) Abandon( ) System located at R 9 0000 7:1,,4 G- 4'.7- A/low• and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. n` Provided:Construction-must be completed within three years of the date of this permit. a f r r Date i / l i i i Approved by �` V,V\j Town of Barnstable. t"E'O�+ti� Regulatory Services Richard V. Scali, Interim Director * ewRtvsrns�.e, 9�p . ,�� Public Health Division Thomas McKean, Director 200 Main Street, Hyannis, NIA 02601 Office: 508-862-4644 Fax: 508-790-6304 Installer & Designer Certification Form Date: I-L. ID ZOIL- Sewage Permit# �o�� 5.�aAssessor's Map\Parcel ��� ��� loo, Designer: r ti ��.� Installer: —31 Address: � ✓� I� Uui(�N Address: C �� � 5 On / o,I—�' �, •-� � 0 was issued a permit to install a (date) (installer) septic system at �� '�^lq 1,5based on a design drawn by 3'AV (address) �? 919D �P-5 dated (designer) _ZI certify that the septic system referenced above was installed substantially according to the design, which may include minor approved changes such as lateral relocation of the distribution box and/or septic tank. Strip out (if required) was inspected and the soils were found satisfactory. I certify that the septic system referenced above was installed with major changes (i.e. greater than 10' lateral relocation of the SAS or any vertical relocation of any component of the septic system) but in accordance with State & Local Regulations. Plan revision or certified as-built by designer to follow. Strip out(if required) was inspected and the soils were found satisfactory. I certify that the system referenced above was constructed ' 1nce with the terms of the I\A approval letters (if applicable) /4�'� 0Fti1,;Lcs Q y DAVID y B. \� Installer's Sianatur tiIASONNo 1066 ` Ig a ,L r T �\ ( esign ignature) (Affix Desib ¢g. affip Here) PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS- BUILT CARD ARE RECEIVED BY THE BARNSTABLE PUBLIC HEALTH DIVISION. THANK YOU.'. Q:\Septic\Designer Certification Form Rev 8-14-13.doc -oil tq Town of Barnstable Pit Department of Regulatory Services Ib M Public Health Division gate A i'63fl �+ 200 Main Street, yannis MA 02601 Date Scheduled— Tiine Fee Pd. Soil u ta �zty�.As�sessmentiror Se e Disp® r � s Performed 13y:�//j�� —�.✓ 9/'/Cl��d l Witnessed By: . J LOCATION&GENERAL INFORMATION Location Address ' Owner's Name Address /`• `j� Assessor's Map/Parcel: ©Cl 'G�i� Engineer's Name NEW CONSTRUCTION� - REPAIR y eeph'one# ✓ Land Use SlopesUL✓/� (46) Surface Stones Distances from: • Open Water Body_ft,. Possible Wet Area ft Drinking Water Well ft Drainage Way ft Property Line ft Other ft SKETCH:(Street name,dimensions of lot,exact locations of teat holes&perc tests,locate wetlands n pmximiry to bolts) //' ti r Parent material(geologic) LDcOvili413aFmol�_ Depth to Groundwater. Standing Water in Hole: Weeping from Pit Face Estimated Seasonal High Groundwater DETERMINATION FOR SEASONAL RIGHWATER TABLE Method Used: Depth Observed standing in obs.hole "?. i In, Depth td 3011 mottles: 1n, Depth to weeping from side of obs_hole:`'s' ln, Gttlundwater AdJuatment ft. Index Well# Reading Date: Index We111eve1 Adj.tkctor Adj.Groundwater Level e — _.. PERCOLATION TEST Date �lYn,a Observation I Hole# Time at 9" Depth of Pero .. — - _ Time at 6" Start Pre-soak Time @ r Time(9"-6") End Pre-soak ' t Rate Min./Inch Site Suitability Assessment: Site Passed Sitp Failed: Additional Testing Needed(YIN) Original: Public Health Division Observation Hole Data To Be Completed on Back----------- *If percolation test is to be conducted within 100' of wetland,you must first notify the. Barnstable Consei}vation Division at least one(1) week prior to beginning. Q:ISEPTICIPERCFORM.DOC DEEP OBSERVATION HOLE LOG Hole# Depth from Sol Horizon Soil Texture Sdil Color Soil• Other Surface(in.) (USDA) (Munsell) Mottling (Stnueturc,.Stones,'Boulders. or sip stency,%Gravel) O) DEEP OBSERVATION HOLE LOG Hole# Depth from Soli Horizon Soil Texture Soil Color Soil Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stones,Boulders. ' � onsisten % a DEEP OBSERVATION HOLE LOG hole# Depth from Soil Horizon Soil Texture golf Color Solt Other Surface(in.) (USDA) (Muuscll) Mottling (Structure,Stones,Boulders. Can i to c G DEEP OBSERVATION HOLE LOG Hole# Depth from Soil Horizon Soil Texture Soil Color Soli Other Surface(in.) (USDA) (Munsell) Mottling (Structure,Stories,Boulders, Cons' ten y,%©mygl) Flood Insurance Rate Map: Above 500 year flood boundary No ZI —Yes YesWithin 500 year boundary No Within 100 year flood boundary No.� Yeses Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pery ou grief exist in al l areas obsorvetl throughout the area proposed for the soil absorptibn system? If not,what is the depth f Naturally occurring pery ous material? 1 qt�. Certification I certify that on (date)I have passed the soil evaluator examination�approved by the Department of Enviro enta Protection and that the above analysis was performed y ma consistent with the req 'red training,expe ' e x ri ce described in�10 CUR 15.M. Signature Date 1Z, Q:\S.RPTICW—RC17ORKDOC Fims... ................ r THE COMMONWEALTH OF MASSACHUSETTS BOAR® OF HEALTH Town Barnstable ...........................................O F...........................----._......--- ApplirFation for Dispuiial Works (> oustrurtiou rruti# Application is hereby made for a Permit to Construct ) or Repair ( ) an Individual Sewage Disposal System at• ¢�CW Tip-C., �• Lot # 2A- 1Aed-. -ra n Ve Hyannis , MA ................__..................-----...............----•--•--.............-----------...... .................--•-•-••---.......-------•-----------------------•.......----------............. Capricorn Re�.jt yATMSt 765 Falmouth Ropa%NEyannis ......... ..... ....... .•-- ....- ...........----...-----------•........_.....--- ------••--•••----•--••-•••---•----•--•-....-----•-••-•-.......................................... Steve'Lebel Owner Address --•........................................................•._....._•---..........--- Installer w Address Type of Building 3 Size Lot............................Sq. feet Dwelling—No. of Bedroorsa21CYi Expansion Attic ( ) arbage Grinder ( ) Other—Type of Building ..... No. of persons............................ Showers — a yP g -•-•••-•-••...:; P ) Cafeteria ( ) Othr fixtures ---- ---------------------------------------------------------------------------------------------- 5 33rOr---------------------------------------- Design Flow..............-..._....._-.-- - . gallons per per l;, v day. Total, ,flow.............................- W - O �i - ns. WSeptic Tank—Liquid capacity.._...._.....gallons Lengt ............... Width._............_. Diameter.............._. Deptl ............... x Disposal Trenc�—No..................... Wid #----_-----------•-- Total Length.......+...........Total leaching area---. sq. ft. Seepage Pit N'`................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution-box ( ) Dosi t ,,.., �l4dg)e Engineering 11-25-81 Percolation Test Re t Performed by......... . . . . .... , -. Date...._.__._.._. r.y IZ nor e----encounte - Test Pit No. -y�:......_..minutes per inch Depth of Test Pit Depth Depth to ground water. A___._....__._. e G� Test Pit No. ...............minutes per inch Depth of Test Pit..............._.... Depth to ground water-..--__--_-.-----------. Fit T.....-•-- P-------- ---------- - - --•-••-•---« ........_..----••---_......_-.._.--•-----___......-_.....__'-------................----- Description of Soil........0_r - loam & topsoil . x -------------•----------------•-------------------------------._......-------- W .............................. med-:---Wh t"e.sand/tr-aces---U f...graveifnv.•.water--at---12 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 TIME 5 of the State Sanitary Code— The undersignedA7ther agrees not to place the system in operation until a Certificate of Compliance h b issu by t e board o alth. ••- Signed &s ..... ....2 26/8?�.. .... Application Approved By••..•-•--7�... -- •-•------ ....................................... / iate Application Disapproved for the following reasons: .............-................................-.......................... ...........................................................•----------•------------------•-•-------...--............-•••--•---- ---...---•------•---•-•--------------•---•---•-------•-••-••----------- C� Date PermitNo.----- --•-------------------•-----•-•------........ Issued........................................................ Date No..9.....t......��C7 FBB....��............... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable - ..........................................OF.......................................................................................... Appliration for Disposal Works Tonotrnrtion Vprrmit Application.is hereby made for a Permit to Construct ( )'or Repair ( ) an Individual Sewage Disposal Syst 0t,:# 2:a Woodland yve. Hyannis , IYA .................;... ......----- st . . .. Capricorn 765 Falmouth RaaTdt,N6hyannis ......................__........................................................................ -••••••-----...................................................................................... Steve ' Lebel Owner Address W Installer Address Type of Building 3 Size Lot............................Sq. feet .., Dwelling—No. of Bedroo nan ..................Expansion Attic ( ) arbage Grinder ( ) A4 Other—Type of Building .........................•.. No. of persons............................ Showers ) — Cafeteria ( ) QI Othn fixtures -----••------------------------------------- W Design Flow................::. :•fflfl0 gallons per pers8q her day. Tot?j��"flow ----• --......-_................g1pns. WSeptic Tank—Liquid capacity.........•..gallons Length................ Widtl7.............. Diameter---------------- Depth.............. x . Disposal Trenchl No. .................... Widbha.................. Total Length..... a.......... Total leaching area.... -6.6--------sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area............------sq. ft. Z Other Distribution box ( ) DosinR1t'+4dde Engineering 11-25-81 Percolation Test Re t Performed by......................................... , Date.._.____....._ .� 2__._...... t,ts e...oyylff ounte�- Test Pit No. t /A..........minutes per inch Depth of Test PiVA............. Depth to ground water.N x..._......____. e GT,, Test Pit No. .....•.......•..minutes per Inch Depth of Test Pit.................... Depth to ground water........................ aa{ ---------1-nai -.&c-..tops-o-fl--------------------------------------------------------------------------- ---------- ODescription of Soil---------24--•_--j-0.........1Vfe di•C12n"'y811-ow"Sand------•-------------- -------------•----•............................... v --••••••...... }{9-a---- _12-'------meal-:---white---sand/'traa-cga---orf`--gravel/na--waterr--at---12 w ...........•--•--•-•--•-- UNature of Repairs or Alterations—Answer when applicable..........................................................................._ .._.... ........... ----------------------------•-------------------------•--•..........._...............•-••-•--•--••-••••••--•••••••••••---••--•••-•---•-•-••......----•••••---•-••••••••••••••••......................... Agreement: The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TIT1Z- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued by the board of health. igned.............................. Pres . 9/26/84 -----------•-•-------... ------ -------• ................_ ApplicationApproved By.................................................................................................. ate Application Disapproved for the following reasons:.................................................................................._......................... _ ....•.•.............•-••--•-------------...--•--••-•-------------•-------------..............---------------------------------------------------------------------------••-......--•-••••-•••......••--- --- Date PermitNo....................................................... Issued....................................................... Date THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Town Barnstable ....................OF..................................................................................... f�rrifirtt#r of Wont�fi�anrr THIS IS TO CERTIFY,.�Pf th--4 d�v dual Sewage Disposal System constructed ) or Repaired ( ) by----•--•-•------.--•--..-------•--•--------••--••--••-------•---------------------•-----.----------•- .----•---•-•- --------•-•-•---------.----•------.--------•-•-----------•--------•--- Lot ;Y 2ti Woodland Ave,. , Installer H--annis, MA at..................................................................................................................................................................................................... has.been installed in accordance with the provisions of TIT I.4, r of The State SanitaryCode as described in the application for Disposal Works Construction Permit No.____.__`z.... -` .q.0.... dated .............................................. THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. DATE................. '- ............................. Inspector.---...... .... THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH _ R Town Barnstable ..........................................0 F..................................................................................... No......................... FEE........................ io�roo�tlVleveorko . o str ion ernti Le e Permissionis hereby granted.............. ----------------------•-..-•••••-•-•---•-•-••••••••••---•.......••-••••••-•......................•••..................... to Cons Nr or an I dividual Sewage Disposal stem . '�c `fir )?..ti F4681 .n�l ki . , g P Tiyannls, irlA at No. r- - Street6 � P..........................•---••-•-----............. - Street as shown on the application for Disposal Works Construction Perm>t? No.__........e=....r(,Date •-•.................................. ........................•----•-------•----•--•-----•---...----•-----.........-•-----•••-..............._ Board of Health DATE ... . .......................•..••--•---•=-----••----•--------•-•---- FORM 1255 HOBBS & WARREN. INC.. PUBLISHERS Commonwealth of Massachusetts Title 5 Official Inspection Forr ,,,.e.,,, w Not for Voluntary Assessments Subsurface Sewage Disposal System Form "4 ' � M 23 F'l 4 12 Inspection results must be submitted on this form or on the official Title 5 Inspection Form dated 6/1 512 0 0 0. Inspection forms may not be altered in any way. A. Certification o z ia) d Important: qt-tAz per When filling out 1. Property Information: ,AP #¢_� forms on the computer,use 89 Pontiac St 4 RCEL '`��°� only the tab key Property Address , to move your Jean &Andrew Hardwick C cursor- not Owner's Name use the return urn key. 89 Pontiac St Owner's Address / Hyannis MA 02601 City/Town State Zip Code Date of Inspection: 02/17/05 Date 2. Inspector: Michael J. Hudson Name of Inspector Septicwiz Company Name 31 Midway Dr Company Address Centerville MA 02632 City/Town State Zip Code 508-367-5669 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 ❑ Needs Further Eval ation by the Local Approving Authority f 02/28/05 ns ector's Si re r iFDate 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. Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 1 of 16 v Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M A. Certification (cont.) 89 Pontiac St Property Address Hyannis MA 02601 Cityrrown State Zip Code Jean &Andrew Hardwick 02/17/05 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: System passes current regulations, no signs of carry over or back up, recommend pumping 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 ❑ 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. ND Explain: Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 2 of 16 z,. Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments s Subsurface Sewage Disposal System Form j A. Certification (cont.) 89 Pontiac St Property Address Hyannis MA 02601 Cityrrown State Zip Code Jean &Andrew HArdwick 02/17/05 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: ❑ 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: 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 Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 3 of 16 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 89 Pontiac St Property Address Hyannis MA 02601 City/Town State Zip Code Jean &Andrew Hardwick 02/17/05 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: ❑ 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: Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 4 of 16 C Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M A. Certification (cont.) i 89 Pontiac St Property Address Hyannis MA 02601 Cityrrown State ZipCode Jean &Andrew Hardwick 02/17/05 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 ❑ ® 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 '/2 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 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 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.] 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. Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 5 of 16 fr. Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M A. Certification (cont.) 89 Pontiac St Property Address Hyannis MA 02601 City/Town State Zip Code Jean &Andrew Hardwick 02/17/05 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 ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone I I of a public water supply well If 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. Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 6 of 16 i Commonwealth of Massachusetts 4 Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M 5vey`' B. Checklist 89 Pontiac St Property Address Hyannis MA 02601 Cityrrown State Zip Code Jean &Andrew Hardwick 02/17/05 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 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(3)(b)] Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 7 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form ° Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information 89 Pontiac St Property Address Hyannis MA 02601 Cityrrown State Zip Code Jean &Andrew Hardwick 02/17/05 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 Number of current residents: 4 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 d 03 495gpd, 04 9 ( Y 9 (gpd)): 519gpd Sump pump? ❑ Yes ® No Last date of occupancy: currentDate Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe): Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 8 of 16 i Y Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form 4M C. System Information (cont.) 89 Pontiac St Property Address Hyannis MA 02601 City/Town State Zip Code Jean &Andrew Hardwick 02/17/05 Owner's Name Date of Inspection General Information Pumping Records: Source of information: Obtained from home owner Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 1988, 17 years, obtained info from previous inspection Were sewage odors detected when arriving at the site? ❑ Yes ® No Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 9 of 16 t . Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 89 Pontiac St Property Address Hyannis Ma 02601 City/Town State Zip Code Jean &Andrew Hardwick 02/17/05 Owner's Name Date of Inspection Building Sewer(locate on site plan): Depth below grade: 3.17' feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: N/A feet Comments(on condition of joints, venting, evidence of leakage, etc.): Pipes were in good conditions, no signs of leakage Septic Tank(locate on site plan): Depth below grade: 21.25"feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) 1000 gallon tank, appeared to be in excellent condition If tank is metal, list age: N/Ayears Is age confirmed by a Certificate of Compliance? (attach a copy of ❑ Yes ❑ No certificate) Dimensions: 8'6"x 4' 10"x 4' 10" Sludge depth: 50" Distance from top of sludge to bottom of outlet tee or baffle 20.E + Scum thickness .5" Distance from top of scum to top of outlet tee or baffle 5" Distance from bottom of scum to bottom of outlet tee or baffle 4" How were dimensions determined? Stick, wrag &flapper, flashlight Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 10 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 89 Pontiac St Property Address Hyannis MA 02601 City/Town State Zip Code Jean &Andrew Hardwick 02/17/05 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.): System is working properly but would recommend pumping. Home owners indicate system was pumped in 2003. 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.): 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): Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 11 of 16 Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form M C. System Information (cont.) 89 Pontiac St Property Address Hyannis MA 02601 Cityrrown State Zip Code Jean &Andrew HArdwick 02/17/05 Owner's Name Date of Inspection Tight or Holding Tank(cont.) Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes❑ No Date of last pumping: Date. Comments(condition of alarm and float switches, etc.): Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert .25 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 was level and intact, flowing properly with no signs of solid carryover or leakage Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 12 of 16 r Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 89 Pontiac St Property Address Hyannis MA 02601 City/Town State . Zip Code Jean &Andrew Hardwick 02/17/05 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: 1/6'w/stone ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): loacation of sas level, no signs of ponding, failure, breakout or odor, vegeatation normal Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 13 of 16 C I` Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form ' M C. System Information (cont.) 89 Pontiac St Property Address Hyannis MA 02601 City/Town State Zip Code Jean &Andrew Hardwick 02/17/05 Owner's Name Date of Inspection 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.): 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.): Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 14 of 16 Commonwealth of Massachusetts W Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form C. System Information (cont.) 89 Pontiac St Property Address Hyannis Ma 02601 City/Town State Zip Code Jean &Andrew Hardwick 02/17/05 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. 4 I I A I - 31 �1 - Zo , I pQ`,i� It $3 " 2no Z IA o y3o 6 �� -3` 4 C) y Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System- Page 15 of 16 f Commonwealth of Massachusetts Title 5 Official Inspection Form Not for Voluntary Assessments Subsurface Sewage Disposal System Form �M C. System Information (cont.) 89 Pontiac St Property Address Hyannis MA 02601 City/Town State Zip Code Jean &Andrew Hardwick 02/17/05 Owner's Name Date of Inspection Site Exam: Slope "D S icy IF Surface water N A Check cellar �,If),n� 5' �„— �; inS ec� 00 rra'�1eMs Shallow wells N J A 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: Date ® Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Obtained previous inspection 7 ❑ Checked with local excavators, installers-(attach documentation) ® Accessed USGS database -explain: Reviewed topo map of site location, contour lines indicate 20'+to high ground water You must describe how you established the high ground water elevation: Checked USGS topo map of site location, reviewed prior inspection, hand augered to 15'at corner of lot without encountering any signs of water. Hardwick Inspection.doc•11/2004 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 16 of 16 �\ COMMONWEALTH OF MkSSACHL'SETTS EXECUTIVE OFFICE OF E\VIRON\IE-\TAL AFFAIRS _ DEPART�IE�T OF ENVIRON:�IE\TAL PROT Ba OBE WINTER STREET.-BOSTON. MA 0-105 E1?•:9=•5:0�. JUL WILLIAN'F.WELD 1998 T 1'COS. Governc ..J _, . ... 60 Se:rca: DA STRL•1 ARGEO PAL-CELLL•CCI - Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO mmissionr HAe — r�l��j PART A " Q���� CERTIFICATION 9 - LoT- (i o Property Address; ���� ��t°`C- S1_1 A63r,)IS 'Address of Owner: t � l-k►>v� Sv�l� L� Date of Inspection: 6(Is kci(b . :Of different) Name of Inspector: HA 9A 04 P ED e-21C - 1 am a DEP ap roved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) ' Company Name:f}z a vr--r'c En y'r'r ,h we to Mailing Address: ,R o /3 ox C_32!f- H 19S Telephone Number: fSG7t;2 CERTIFICATION STATEMENT - I cerlf that I have personally inspected the sewage disposal system at this address and tha: the information reported below is true. accurate and comolete a: o:the time of inspectoo The inspection was performed base-- on my training and experience in the proper function and maintenance o;on-s-te sewage disposa; systems. The system: Passes — Concmonaii- Passes leecs Further E% the Local Approving Authorm — Fa.!s Inspector's Signature. Date: '.ae Svste-r Insaeco• sha!' submit a copy of this inspecion report to the Approving Authority- within them, (30) days of completing this inspection. If the system is a shared' system o• ha= a design flow of 10,000 gpd or greater, the inspecor and the system owner shall submit the repo,: to the appropriate regional office of the Depa-ment of Envvonmenta' Protection. The origma! should be sent to the system owner and copies !-rit to the buyer, if applicable. and the approving authority. INSPECTIO%SUMMARY: Check A, B, C, or D' AI SYSTEM PASSES: : I have not found any information which indicates that the system vioiates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. . COMMENTS: ,C i � fi ' 1 c BI 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. Indicate yes, no, or not determined (Y, N. or NDi. Describe basis of determination in all instances. If'not determined explain why not. The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance lattachedi indicating that the tank was installed within twenty (201 years prior to the date of the. inspection; o� the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (rer:aed D�/35!!7) page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM I ` PART �.. .. . CERTIFICATION (continued)AkJ Property,-Ac$55: Date off lns C.Bj'SYSTE.MACONDITIONALLY.P,ASSES tcontjn,�6d - _ r high static water level observedm h i distribution box i duebroken r• r Sewage backup or breakout o h g sta c a ,t e d s s d to o obstructed g pipes) or�6e to a broken, settled or uneven distribution box. The system will pass inspection if(with approval or the IAIN�t1t toard of•Health).. Describe observations: V .. broken pipe(s) are replaced .. _ obstruction is removed - .,�g'; 4 Y distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets).,The system will pass inspection if twith approval of the Board of Health): broken pipe.si are replaced obstruct o i r. is removed r -�. . C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require furthe•evaluation by the Board of Health in order to determine if the.system is failing to protect the public health. safer•and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM 15 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. Cesspool or prnti is within 50 feet of a surface water Cesspool or prn, is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM "'ILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT . THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption.system (SAS) and the SAS is within 100 feat to a surface water supply or tributan• to a surface water supply. The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supri'y well. _, The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less char. 100 feet but 50 feet or more from a private water supply well, uniess a well water analysis 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. Method used to determine distance (approximation not valid). 3) _.OTHER (revived 0�:25/!'1 Page 2 of 10 SL 6SURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Propertv Addrross: Owner: Date of Inspection: DJ SYSTEM FAILS: You must indicate either 'Yes` or `No' as to each of the folio,-ing: have determined that the system violates one or more of the following failure criteria a< defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or pondrng of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Sta:lc hcutd levei in the distrnb i on bo). above outlet invert due to an overloaded or clogged SA,5 or cesspool Liouid depth to cesspool is less than 6- below invert or available volume is less than 1/2 day floe. i Reeu"red pumping more than 4 times in the last year NOT due to clogged or obstructea pipe s . Numoer o:times pumped _ An: portion of the Soa Aosorpuon System, cesspool or privy is below the high groundWate• eieyat,oc Ar.. por:on o' a cesspool or pri.-�- is withir. 100 feet of a surface water supoly or tributary to a surface water supple And por,on of a cesspoo' or pri.%• is N ithar a Zone I of a public well. Am pe^jor% of a cesspool or privy is within 50 feet of a private water suppl} well Am• por.,or. of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceo-,able v.ater qualm analvs,s. If the we!I has bean analyzed to be acceptable, attach copy of well water analysis for cohiorm bacteria volatile organic compounds, ammonia nitrogen and nitrate nitrogen. - i E] LARGE SYSTEM FAILS: You must indicate either -Yes` or -No- as to each of the following. The folio%:r.g criteria aop*,v to large systems in addition to the criteria above: The system serves a facilir, with a design flow of 10,000 gpd or greater (Large System; and the system is a significant threat to public health and saiety and the environment because one or more of the following conditions exist. 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) - The owner or operator of any such system shall bring the system and faci)iry into full compliance with the groundwater.treatment program requrrements..of 3141 CMR.5.00 and 6.00. Please consult the local regional office of the Department for_further.iniorma1104. trwis�d 0{/15/9'1 r..,. ] of to r f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: i Ni 1(Ac- Owner: V l \+U�J Date of Inspection: Check if the following have been done: You must indicate either 'Yes' or 'No" as to each of the following: es No Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.. As built plans have been ootained and examined. Note if they are not available with NIA. The fac:lia or dwelling was inspected for signs o;sewage back-up. x Tree system does not receive non-sanitan• or industrial waste flow. �C _ The site "as inspected for signs of breakout. _ All systeT component:. excluding the Soil Aosorpuon System, have been located on the site. • . The septic tank manholes "ere uncovered. opener'. and the interior of the septic tank was inspected io' condition of '] barfies or tees. materia� o' construction, dimensions, deptn of liquid, depth of sludge. depth of scum. The size and location of the Soil Absorption Svstem on the site has been determined based on The fac-lin o"ne• .ano occupants. ii dirteren: from o"nert were provided with information on the prope, maintenance of Li, Sub-Suriace Disposal 5ysterr.. i Existing information. Ex. Plan at B.O H. _ Determined in the field ttf an\ of the failure criteria related to Part C is at issue, approximation of distance is unacce:)tabie (13.302;3t:b1t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORJM PART C SYSTEM INFORMATION Propert% Address: i �C�KrtA-U Owner: ti l MCK Date of Ihspection: c' l 1 FLOW CONDITIONS RESIDENTIAL: Design flo% o.d.lbedroom for S.q., Number of bedrooms Number o current residents JO-3 Garbage g•::der (yes or no:: N Laundry co:—ected to system (yes or no! Seasonal use (yes or no,: _4 Water meter readings, if ava fable (last two f2 year usage tgpdi: iV Sump Pump Ives or na Lai: date o occupancy _�hNCCIV.A- 15 Ckk)% Ve IGYI.� COMMERC;4L'INDL.'STRIAL: Type of establishment Design fio%% gahonsida,. Grease trap present tees or no_ Industria! haste Holding Tani: present. lees or no ':on-sancta-, v`aste d.scnarg�• to the T!tie S systern ,ves or no— \%ater meter readings if avaifabie Las:pave o: o OTHER: .De:cribe Last date of occuoa-,c. GENERAL INFORMATION PUMPING RECORDS and source of information ��cl. e., eL)IM ��c� IT '�n11 c T INN t System pumped as par, of inspection: (ve or no �— s . li ves, volume pumped gallons Reason for pumping TYPE OF SYSTEM Septic tank,/distribution boxrsoil absorption system Single cesspool Ovenlow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) - I/A Technologv etc. Copy of up to date contract? Other - APPROXIMATE AGE of all components, date installed (if known) and source of information: U QyLs Sewage odors detected when arriving at the site. (yes or note (revimed 0{/25/9'7) Page 5 of 10 SUBSURFACE SEVVAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: j5 Qt-m ftte� Owner:M% VtzYV . Date of Inspection: /_ (S(cis BUILDING SEWER: (locate on site plan) Depth below grade. Material of construction. _cast iron _40.PVC _other (explain: Distancefromprivate water supply well or suction Ire Diameter Comments: (condition of joints, venting. evidence of leakage. etc.) SEPTIC TANK: (locate c sue pla. Depth below grade Material of construction' _concre.c _me:z _Ftoerg;ass _Polyethylene _othertexplain If tank is me-,a:. Lis: age _ 1; age coniirmec o% Ce-:.iica:e c: Compuance _(l es.-No Dimensions Sludge depth C it Disiance from top o: s:ucee to bororn o- ou:ie: tee o• ba-;;e Scum thickness- �( Distance from top o: scum to top o` outle: tee or bz-:,e Distance irorr, bosom o-scurn to bo-o-- o;out)e: tee e• bane Now dimensions were determined Comments trecommendation for pumping. rondition o� iniet and outlet teas or baffles. depth of liquid leve! to reiauon to outlet invert. structural integrity, evidence of leakage. a:c.t (n, Q-' GREASE TRAP:—Eb (locate on site plan: 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 bonom of outlet tee or baffie: Date of last pumping: Comments: —" (recommendation for pumping.-condition of inlet and outlet tees or baffles, depth ofliquid level in relation-te-oudet-invert;structur-al- :ntegnty, evidence of leakage. etc.; 1 ' Y�7 �9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR.m PART C SYSTEM INFORMATION (continued) Propert% Address: �6N l 1 F}-c, O%ner:j-�t Date of Inspection: 6-8 TIGHT OR HOLDING TANK: -Tank,must be pumped prior to, or at time, of inspections (locate on site plan, Depth below grade. Material of construction. _concrete _metal _Fiberglass _Polyethylene —other(explain) Dimensions. Capacm: gallons Design flo' gahons.-da. Alarm level Alarm in %;orkrng orde• _Yes. _ No Date of previous pu:.nping Comments (condition of inlet tee. condition o- a'a-m and float switches, etc.) DISTRIBUTION BOX:Vs (locale on site p:a- 1 ear r,. T fJ V L,I D of liould le.e uu : m ^. � : aoo�e oe �e �f ��•,J� Comments � mote :f I ve a:) dis:r!buro . is ua' evidence of solids ,�rr}•over, evidence of le ka a into or out of boa, etc.) � �S r PUMP CHAMBER: ,ltl (locate on site plan. Pumps in working order: (Yes or No, Alarms in working order (lees or No Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) , SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORti1 PART C SYSTEM INFORMATION (continued) �l rl r Property.Adrfrass: Port � Owner. % 1-Trj VJ Date of Inspection. SOIL ABSORPTION SYSTEM (SAS): (locate on site_plan, if possible; exca. ion not required, but may be approximated by non-intrusive methods If not determined to be present, explain. Type ,GN Y' leaching pits. number. Wi � leaching chambers, number:_ leaching galleries, number. leaching trenches. number,length: leaching fields, number, d,rnensron.s overflow cesspool, numbe- Alternative system Name of Tecnnoiogv Comments to a condition of soil. s+gr.s of by ulic failure. ev ponding. co a1on of egetpn, etc.)atielo � Y " 3 _ , J CESSPOOLS: (locate on site play. Number and config-jra:-or Depth-top of liquid to inlet Inver, Depth of solids lave- Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundv ate- infloK• (cesspool must oe pumpec as pan of inspection: Comments. (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: �v (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.); (z.va■.e 04/15/97) Page a of 10 c' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Pcti� l Owner. N t mo IJ Date of Inopection: SKETCH OF SEWAGE DISPOSAL SYSTEM. include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) Ae6 G a 3(0 i 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Propertv AddresF• ( �� Owner: itl t 1N Date of Inspection: 6 1 5 1�� g, 1 Depth to Groundwater yFeet Please indicate all the methods used to determine High Groundwater Elevation: _ Obtained irom Design Plans on record Observation of Site tAbuning property. observation hole, basement sump etc.) Determine it from local conditions Cnec� with loca! Board o• nea;tr Chec'K FE.MA neaps Check pumping records Check local excavato,s installers lse t5C5 Data • 0 De sic ribe in .our o%.-. %••oros r.o••+CCo:. es:acihshed the �-iigh Groundwater Elevation. (Must be completed: lrw.ud 0�;25'9'. Page 10 of 10 ap FT. ./ /N. rNE.? T.�' _ !G TA Al `p�q __.-. 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T'HE _ a'".F'i Wv- O�SUD r�y,Y:�-. _ � ��S'•. 1 1, r a { �; n1X��M1Z�Y��S f�y i.� �: .t .) 4 .,u, JS` ; REd9 'f:ERE® fix.. x + +dg,l t� ;r. 1 �&�t 1NG 8 4`0WN- ON THI PLAk� ; �� N� � t k_K. p �-tv.�\ r, . � � '4 � hr :j'tr1 �t .>p n F e:._,. !,* �® .hz ak ;R y ;.:�� �Fs. + LAIND x, r . �� „' c i F S? z 6�ORFOIR sS',r TO 2 HE Otl'�, , .� R,V. �', t4/���D 1"� d.t { �'t."` a _t,, l•`�s ;r, �v;r�-!�"�f��7 �'F?�A_�.-F M:A: cat'. a 1� �..7y x .�e''•.,y �...:,:,;�n r... �s+#) Y� W � hat lijY!`" .Jk+f "Z e i �' i��. - IS :i. t y Et E• _ ''laAy 9v3'A 4 N S,TR E ET ;, Pf "'xt 7 .s S'•�' ps�,'•9 SS fs,� v �l�ii o� � c e. ��:ek "`p ')�a.'.� �} r:�a �J�r,;./` ,,;,— '\ l :? =""r t �j .r', 'a;'.: S RypAe�y pp ppy, y�ypv ,Epp pq�ryR �r..i �},5 1}`1 )� �J,' -WY. .,. .:, � R^'V •��iP .4� 'tl:S,�Yr�Yt+ul� �{ l ��sir y°r Sad e �..1. r ! i � a "-,ea ri .�•�4^r .rt2�,&� a ' =:z ` � eL.:.. �lrt �.,' - �E% ��� ,g � _' - ffl,'R if If u I I �SASSESSORS MAP : Irt TEST HOLE LOGS k % , t 1, x• PARCEL: _r _�._.. _ 1) The installation shall�arrit�l ide V Town of ward of. v }iiftl� T SOIL EVALUATOR O�C FLOOD ZONE w _PP health Re ula ions f� 1, _ ------- --- - ___ WITNESS :. � � , Q 2) The installer sl1a� reiiy,the loeattort of tttlities, sewer inverts and septic REFERENCE: t o _.. _-. _ DATE: cord onents rro ' _ _ ._ ._.. �� ._ ;� ; �� �� r ;, �?kl��setting base elevations:.. � . . �'� �..�.._�--- P p . td iti��allatlori,a d` PERCOLAT I OtJ RATE:L ?i l 3) All gravity eptiq off, to b ;4'irict%Sch 4l1 PVC at l/8" per Foot. The First D,Db Q two feet out of th1 + to the Ilia }ringshall be level. c`JT' 1 ' -►t 1-- 4) This plan is not '1 ' 'h. 1tl;<ze'i f TH- I T 2 purpose #' pl p1c� erty Fine determination nor any other u ose other t lroposr system installation. �� Hfi 5) All septicori t�st 11e' t i�� V specifications, 1' 6) Parking shall nC "c �nstruCtedrovle H 1 Q peptic components. a, N d i 7) The properyiis Dried by;pioperft ,comers and property lines. 1� l 8) The`proper y o vrier shill revi,evr d sigriltd s;<derations to approve of total .� P �: +: I,h� design Flow and,rittmbr of bedrndtn to be considered for design. Receipt LOCATION MAP '�j � of payment forxhe plant and mist"Nation based on the plan shall be deemed ' �� tU QS�,` l approval,of the destgri Flaw byhe 9) The existing leaohllig oXesspools still be pumped,and filled with material Alf �1•• be removed alona�w,tli ontarn Hated soil and replaced with Pclean sand pe shall p p Those within the proposed S , g , P and per Title V ' ecs �; 10)System Compotie iso, 10'.te f�olr#�%ater line. Sewer !fines crossingthe \ o l ds _� water lines alh,l);„ ee with rich SG1140 PVC with ends grouted of e applicable `oseSA J5.be n installed below the water service , l line. Ths line is to be s evedias afq� mepooned and maintained in place.' SEPT IC SYSTEM D E S I G N 11) If a garbage gri. r etc' i§ rt is to b I `emoved and is the responsibility of the owner to ensure siachl I �#4,1 i,`flzi (� t FLOW ;EST 1 MATE 12)The installer,is io_take c Utiob4fi excavation around the gas line if such 10 - - - exists. �FJ p � BEDROOMS AT �'� GAL/DAY/BEDROOM - GAL/DAY installer shall verify the location; quantity,and elevation of the sewer - ^ -- 13j linesexit n� the dwellm rior to I y Q f g p thetnstallation. M SEPTIC TANK 14 This larR is re resentati' elonl that a system can fit on a property meetrn l I '� w ) P P ;Y Y p P y g ,, . 0 1r I —rr Title V re wrementss i 1, i GAL/DAY x 2 DAYS - GALS (V USE DOO GALLON SEPTIC TANK 4 SO AR5C1R Oifi''SYSTEM----------... � c tY ,� ,.0 r'. v.�«,NI,,.. uM��,•,,.t�,,, _ I, �.�f" ,y ,>:.:-.A ,i, „``� :..'S. s 'SIDE AREA: IL I. nab DAVID; 9� rn , I . _ _;BOTT M AREA Z I� f ] / t W ,�Ak /�,P II idl }5'' o EPT I C SYSTEM SECT I ONr (e , N� two, Y ...._. I.Da_. 444 1 y I ice' I / �l ?' , ��, I G, pp V�pI b V } �,' 6.o...p.. b n R.7C t I 4J C\J �I(JJ , rrs t1? x t O GALi 'I , }i -- F, � / � �� I�1.� 41/•-71}f��etk:t0}I I x�,, °t x �'xr� I,:}'S'tifj� k�. " t• ''.K"i�l � "� f: SEPTIC TANK 6 I 1 !I r + II Ir �Jaj log, , Ilfl�tli)I lit" ! - t r1 ��r �� _ I(A� _ _ �e i}: � - 1In I'I��,i)f;•>rl{:i1tt[•.� �e a�± � : ey h�l it �d { � ' �£ !�/ I' {1�Y\,y►^�,','J, Il if I l YYY` Uy[ f�, �' t �£� A-S 3 1 � m 1`+J�I .�, 1. I 49.'LHG 'IP11= P L1i. (Akill I\iILM VJ" ' r r% e i19f YA /. O r ;ll ?{•A E• ' d' 1131;. I Ilir�lf►it I, a r I,1 t �,ryf S L : W �: f ��I` I I ` I' ` �, � ' •��l � n ;f�li ��. _. _ ... rli��i4 i � Itil �,r �` � rt„ I�I� }I i; f ,r � DATE a 11i TeC ' + 1 NM AL id SIGNS 1 AS I I 1 3 I f� AT : ANO, I.0 „ t ! it lii;l 3 DATE 2 i 7l�! W HEALTH AGENT I� Z t 508 r , !� _ 1�(i l" kY'Cr•:r' l l l f!' a f E r� i. I;