HomeMy WebLinkAbout0430 SCUDDER AVENUE - Health 430 Scudder Ave"
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Health Master Detail http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=288009
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Application Center Parcel Lookup Selection Items Reports
Parcel I Septic Perc Well I Fuel Tank
Parcel: 288-009 Location: 430 SCUDDER AVENUE,HYANNIS Owner: PLUNKETT,GREGORY KENT
Septic 1,4/7/1994 New Septic...
Permit number: 1994146 Permit type:1.SelecttyRe � Complete system. r•
_
Issue date 4/7/1994 Complete date : 7114/1994
Septic tank size: Type/Size of SAS: I._
Installer: Select Installer Card on file: r
I/A service type: Select service Innovative/Alternative Technology type: Select IA type__ __ s :
Variance date : F Abandon complete date :F ... ..-, Abandon permit number: ,-
Repair deadline date : 1/7/2014 Repair notification date : 1 1/712 013 Keyword:
Comments: NEW O NDeleteSeptic, :I
Inspection liJZZ/2013 Inspection 10/24/2013 New Inspection...
Number Inspection Date Inspector Result
:
Received Date Comments
.....
10/21/2013 inspected by James D. Sears, conditional jY y,Delete I
pass - 11/22/2013 2nd inspection done by Douglas A. --
Brown, passed. DZM observed.jmf
12l10l2013 „..
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http://issgl2/intranet/healthMaster/HealthMasterDetail.aspx?ID=288009 3/17/2014
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Town of Barnstable Barnstable
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MASS�' Regulatory Services Department Q p
•�pb�3yy�p'l A1� .
Public Health Division m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 SECOND NOTICE Richard Scalie,Acting Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7012 1010 0000 2851 2569
March 5, 2014
Gregory K. Plunkett
19 Hawthorne Road
Wellesley, MA 02481
•
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE,TITLE 5
The septic system located at 430 Scudder Ave, Hyannis,MA,was last inspected on
10/21/2013,by James D. Sears, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• The Distribution box needs to be replaced
You are ordered to repair or replace the septic system within sixty (60)days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
" PER ORDER OF T E BOARD OF HEALTH
Thomas McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\conditionally passed\430 Scudder Ave HY Nove 2013.doc
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Gregory k. Plunkett
19 Hawthorne
Wellesley, MA 02481
Certified Mail Provides:
e A mai ft-receiX,
o A unique identifier for your mailpiece '
o A record of delivery kept by the Postal Service for two years
Important Reminders:
a. Certified Mail may ONLY be combined with First-Class Maile or Priority Mail®.
o Certified Mail is not available for any class of international mail.
o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
o For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for,
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
e For an additional fee, delivery may be restricted to the addressee or
addressee's authorized aent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted-Delivery.
n If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail. r
IMPORTANT:Save this receipt and present it when.making an inquiry. '
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
3
• • mgg-
• •
■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. El Agent
% X
I ® Print your name and address on the reverse Addressee_
so that we can return the card to you. B.Rebeiued by(Printed Name) e of Delivery
• Attach this card to the back of the mailpiece.
or on the front.if space permits.
D from item 1 V ❑ es
1. Article Addressed to: If nter defy s below:- N
7--)
Gregory k. Plunkett
19 Hawthorne. i
3. Servige
Wellesley, MA 02481 ❑Certifiod Mail OlExpress Mail
❑Registered ❑Return Receipt,for Merchandise
❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. ,Article Numberr ! t i t i t
(Transfer from service label) 7012 1010 0 0 0 0 2 8:51 2 5 6 9 1�1 ,
PS Form 3811._February 2004 Domestic.Return Receipt 102595-62-M-1540
i
UNITED STATES POSTAL SERVICE First-class Mail I
Postage&Fees Paid
USPS
Permit No.G-10
•Sender,,Please print your name,.address, and ZIP+4 in this box•
Town of Barnstable
Public Health Division
200 Main Street
Hyannis, MA 02601
ttt✓E
Town of Barnstable Barnstable
Regulatory Services Department Q p
D
Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 SECOND NOTICE Richard Scalie,Acting Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7012 1010 0000 2851 2569
March 5, 2014
Gregory K. Plunkett
19 Hawthorne Road
Wellesley, MA 02481
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 430 Scudder Ave, Hyannis, MA,was last inspected on
10/21/2013,by James D. Sears, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• The Distribution box needs to be replaced
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF THE BOARD OF HEALTH
10/21/2013 inspected by James D. Sears,
Conditional pass— 11/22/2013 2"1
inspection done by Douglas A. Brown,
"passed". DZM observed; gave a conditional
pass.jmf 2"d ltr 3/5/2014
Q:\SEPTIC\conditionally passed\430 Scudder Ave HY Nove 2013.doc
Thomas McKean, R.S., CHO
Agent of the Board of Health
QASEPTIC\conditionally passed\430 Scudder Ave HY Nove 2013.doc
Parcel Detail http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=21757
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Logged In As: Parcel Detail Tuesday, March 4 2014
Parcel Lookup
Parcel Info
Parcel __-._. ___. _._.. _.__.____. ._ _..... Developer
ID�288-009 Lot
Location 430 SCUDDER AVENUE I Frontage Pri 15 —�
Sec Sec -- --___. _____ __ _
Road Frontage
Village H Fire
� District
Town sewer exists at this Road I1440 �
address{No Index
Asbuilt Septic Scan: t �
2$$009 1 Interactive
Map n7r 1
288009_2 �
Owner Info
Owner PLUNKETT, GREGORY KENT _ Co-
Owner
Streetl 119 HAWTHORNE RD � Street2
City WELLESLEY State MA Zip F02481 I Country F
Land Info
_ _ _
Acres 0.35 __...,._....� Use(Single Fam MDL-01 Zoning�RF 1 —J Nghbd�0106
ography�LeveI
To
p + Road Paved
Utilities Public Water,Gas,Septic Location ear Location
Construction Info
....._.... __ .. _..._. -..... _ .. ...
Building 1 of 1
Year 1994 �) Roof Gable/Hip Ext Wood Shingle
Built Struct Wall
Living Roofs AC
Area�1080 Cover I'"sph/F GIs/Cmp Type None
WQ
Style Ranch Int Plastered Bed 3 Bedrooms pK�
Y ��._._ _.� Wall�� ____) Rooms
11
Model Residential IntCarpet �� � Bath Full w ;
Floor Rooms
R.
..
Grade IA evlA age —) 'Heat FHot Water —) Total -5 Rooms
Type Rooms , •
P x��
Stories F1 Story Heat Fd s Found-li3 u ed Conc. ,
Fuel�" ation
Gross
http://issgl2/intranet/propdata/ParcelDetail.aspx?ID=21757 3/4/2014
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Town of Barnstable Barnstable
� 'RN-
' Regulatory Services Department j
i639• ��'
prFDa Public Health Division
m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard Scalie,Acting Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7012 1010 0000 2851 1012
November 7, 2013
Gregory K. Plunkett
19 Hawthorne Road
Wellesley, MA 02481
• ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 430 Scudder Ave, Hyannis, MA, was last inspected on
10/21/2013, by James D. Sears, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• The Distribution box needs to be replaced
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification. .
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF E BOARD OF HEALTH
d
o s McKean, R.S., CHO
• Agent of the Board of Health
Q:\SEPTIC\conditionally passed\430 Scudder Ave HY Nove 2013.doc
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[ O Certified Fee
C3 Po tmark
Retum Receipt Fee nerey
OD (EndorsemenYRequired) i v5Q.
Restricted Delivery Fee
O (Endorsement Required)
Total Postage&Fees
fl.l
c" Gregory K. Plunkett V
19 Hawthorne Road
Wellesley, MA 02481
Certified Mail Provides:
e A mailing receipt
o A unique identifier for your mailpiece
o A record of delivery kept by the Postal Service for two years
Important Reminders:
e Certified Mail may ONLY be combined with First-Class Maile or Priority Mail@.
o Certified Mail is not available for any class of international mail.
e NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables,please consider Insured or Registered Mail.
e For an additional fee,a Return Receipt may be requested to provide proof of
delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPSe postmark on your Certified Mail receipt is
required.
o For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery.
e If a postmark on the Certified Mail receipt is desired,please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed,detach and affix label with postage and mail.
i IMPORTANT.Save this receipt and present it when making an inquiry.
Ji PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047
I
A
• Complete items 1,2,and 3..Also complete A. Sign ure 1
item 4 if Restricted Delivery is desired. ; ❑Agent
® Print your name and address on the reverse ❑Addressee
so that we can,return the card to you. Received by(Printed Name) C. Date of Delivery
o Attach this card to the back of the mailpiece,
or on thE! ront if space permits.
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: ❑No
I
r
y~ E
I r ' ,orY K. Plunkett
19'Hawthorne Road 3. Service Type
Wellesley, MA 02481 ❑Certified Mail ❑Express Mail
❑Registered ❑Return Receipt for Merchandise
- ❑ Insured Mail ❑C.O.D.
4. Restricted Delivery?(Extra Fee) ❑Yes
2. Article Number
(Transfer from service iabep 7 012 1010 0 0 0 0 2 6 51 1012
PS Form 3811.Februarv-2004 Domestic Return Receipt, 102505-024M-1540
I UNITED STATES POSTAL,SERVICE ^`r
Firs`f�la��Mail
yPo &&fees Paid
+ / P No :,�
110
. �
Sender: Please print your name, address, and ZIP:4L
an this )C V
YI
I
I � I
I Town of Barnstable
I Public Health Division j
200 Main Street
I Hyannis, MA 02601.
I
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� IT `" Town of Barnstable Barnstable
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9�"�MASS.�' Regulatory Services Department j�`Ce�j
i639 10
fD MAta Public Health Division
m
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard Scalie,Acting Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7012 1010 0000 2851 1012
November 7, 2013
Gregory K. Plunkett
19 Hawthorne Road
Wellesley, MA 02481
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 430 Scudder Ave, Hyannis, MA, was last inspected on
10/21/2013, by James D. Sears, a certified septic inspector for the State of
Massachusetts.
The inspection of the septic system showed that the system "Conditionally Passes"
under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the following:
• The Distribution box needs to be replaced
You are ordered to repair or replace the septic system within sixty (60) days from the
date you receive this notification.
Failure to repair/replace the septic system within the deadline period will result in future
enforcement action.
PER ORDER OF T E BOARD OF HEALTH
-Tifa
on s McKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\conditionally passed\430 Scudder Ave HY Nove 2013.doc
Parcel Detail http://issgl2/intranet/propdata/ParceiDetail.aspx?ID=21757
F
t
Logged In As: Parcel Detail Tuesday, November 5
2013
Parcel Lookup
Parcel Info
_ _... ......................
Parcel r Developer
ID 1288-009 Lot
Pri
Location i430 SCUDDER AVENUE ' Frontage 115
Sec Sec
Road Frontage
Village HYANNIS , Fire HYANNIS
District
Town sewer exists at this Road
1440
address No Index
Asbuilt Septic Scan: 5
288009 1 Interactive
MapI3 �
288009_2 � ,u
Owner Info
Owner JPLUNKETT, GREGORY KENT owner
'
r
Streetl,19 HAWTHORNS RD Street2 F_---
City 1WELLESLEY State MA Zip 02481 I Country
Land Info
Acres;035 Use Single Fam MDL-01 Zoning RF-1 Nghbd 0106
Topography Level � Road
Utilities IPublic Water,Gas,Septic Location Rear Location
Construction Info
Building 1 of 1
BeatYer i1994 j SRoof Gable/Hip (uctWall Ext,W oo d Shingle I
Living Roof _ ACN
_
Area 11080 CoverAsph/F GIs/Cmp Type one
Int —__.____. Bed r—^--- wc;
Style Ranch ( Wall Plastered Rooms 13 Bedrooms �>�
Int _ Bath
Model FResidential I Floor Carpet Rooms2 Full
Alt$;
Grade Average Type Hot Water Rooms I Rooms a $ TT
_11
Stories 1 Story J Fuel lGai'-as_^T Found-
Fuelation Poured Conc.
Gross
http://issgl2/intranet/propdata/ParceiDetail.aspx?ID=21757 11/5/2013
PAY
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner Owner's Name
information is Hyannisport MA 02647 10-21-13
required for every
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:out forms
A. General Information
filling out forms _ ��lpuunuprp�r
on the computer, �`�`�P�SN OF MqS
e m move tabyour 1. Inspector:
key the
cur to
S.
James D.Sears -\ I� Imo? JAMES m
use the return Name of Inspector ?L): :y key. =�r •.
CapewideEnterprises,LLC ; �'•_o, o
Company Name
153 Commercial St, i��oi,F S INN SrtP�
Company Address
11
Mashpee MA 02649
CityrTown State Zip Code
508-477-8877 S1623
Telephone Number License Number
B. Certification
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 IS.000). The system:
❑ Passes ® Conditionally Passes ❑ "WFa Is ;
❑ Needs Further Evaluation by the Local Approving Authority ,
✓O 41°�
10-21-13 '
ors Signature Date
The system inspector shall submit a copy of this inspection report to the Approving AWthorit-)"I( oard
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.
UC 4 L� �
t5ins•W13 Title 5 Offal Inspection Form:S b Sewage Disposer System•Pape 1 or 17
Vci L 1 1.5 1 1:Oop p,z
Commonwealth of Massachusetts
Title 5 official Inspection Form
taw-.IBM Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
it Wr--j 430 Scudder Ave
Property Address
Kent Plunkett
Owner Owners Name
information is
required for every Hyannisport MA 02647 10-21-13
page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E 1 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:
8) 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 ofHealth,.w'ill pass.
Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If°not
determined,"please explain.
The septic tank is metal and over 20 years old' or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass
inspection if the existing tank is replaced with a complying septic tank as approved by the Board of
Health.
A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins•3113 Title 5 Official Inspection Farm:Subsurface Sewage Disposal System•Pape 2 of 17
Uct L I I o I I:cop p.,)
Commonwealth of Massachusetts .
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner Owner's Name
information is
required for every Hyannisport MA 02647, 10-21-13
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
❑ Pump Chamber pumpsfalarms not operational: System will pass with Board of Heafth,approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cunt.):
I
® 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):
0 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):
Need to replace D Box.
❑ 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.
I. 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
t51ns•3/13 TiUs 5 Official Inspeefian Form:Subsurface Sewage Disposal System•Page 3 of 17
VGL L I IJ I I:oop p•4
Commonwealth of Massachusetts
ffil Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner owner's Name
Information is
required for every Hyannisport MA 02647 10-21-13
page. City[Town State Zip Code Date of inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, If any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system(SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well'".
Method used to determine distance:
This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must Indicate"Yes"or"No"to each of the following for all Inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an 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 is,less than 6" below invert or available volume is less
than Yz day flow 1 i 7—
t5ins.3M3 Title 5 Offtiai Inspection Fam Subsuface Sewege Disposal System Page 4 of 17
ULA L I IJ I.I.UOIJ pup
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form.-Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner Owner's Name
informaSon is
required for every Hyannisport MA 02647 10-21-13
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cunt.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS,cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria Indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ The system fails.I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,0oo 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
0 the system is located in a nitrogen sensitive area(Interim Wellhead Protection
Area—IWPA)or a mapped Zone Il of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed.The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13
Title 5 Ofridal Inspection Farm Subsurface Sewage Disposal System-Pape 5 of 17
uct2-i -is -i-i:bap p.ID
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
' Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner Owner's Name
information is required for every Hyannisport MA 02647 10-21-13
page. Cityfrown Stage 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
❑ 0 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?
0 ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example,a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable)[310 CMR 15.302(5)].
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t51ns•3113 Title 5 Dlficiaf Inspection Forth:Subsurlace Sewage Disposal System-Page 6 of 17
VC[CI 115 1 l:o/p p.I
'Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner owner's Name
information is required for every Y p H annis ort MA 02647 10-21-13
page. City/Town State Zip Code Date of Inspection
D. system Information
Description:
The system is at 1000 Gal.tank D Box and pit.
1
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system?(Include laundry system inspection E] Yes ® No
information in this report.)
Laundry system inspected? ❑ Yes ® No
Seasonaluse? ❑ Yes ® No
2011-39,000Gals
Water meter readings, if available(last 2 years usage (gpd)): 2012-41,000Gal's
Detail:
Sump pump? ❑ Yes No
Last date of occupancy: Present
Date
Commerciallindustrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203): Gallons per day(gpd)
Basis of design flow(seats/personslsq.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:
t51ns•3113 Thle 5 OMcJW hapocbon Form:Subartface Sowage Disposal System.Page 7 of 17
Ucl L I IJ 11:5/p P.o
Commonwealth of Massachusetts
_ Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner Owner's Name
information is required for every annisport MA 02647 10-21-13
-H y
page. Cityfrown state Zip Code Date of inspection
D. System Information (cost.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
NA
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,Jf any)
❑ Innovative/Altemative 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):
f5ins-3fl3 Title 5 Oftial Inspection Form Subsurface Sewage Disposal System•Page 6 of 17
Vct L l 16 '1 I:oop P.
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
f 430 Scudder Ave
Property Address
Kent Plunkett
Owner Owner's Name
information is nn H ais Ort
required for every Hy— p MA 02647 10-21-13
page. Citylrown state Zip Code Date of Inspection
D. System Information (cunt.)
Approximate age of all components, date installed(if known)and source of information:
1994 Permit#94 146
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 20'
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.):
Pipeing is 4" PVC SCH 40.
Septic Tank(locate on site plan):
9„
Depth below grade: feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000Gal. Precast
Sludge depth: �
't5ire•3113 Title 5 Official Inspection Form:SubsuAaoe Sewage Disposal System-Pape 9 of 17
V Vl G I I J 1 I.00P - - P. IV
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner Owners Name
information is Hyannis port MA 02647 10-21-13
required for every p
page. Cityrlbwn State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
29,r
Distance from top of sludge to bottom of outlet tee or baffle
1n -
Scum thickness
Distance from top of scum to top of outlet tee or baffle 811
Distance from bottom of scum to bottom of outlet tee or baffle 17"
How were dimensions determined? Asbuilt-Tape
Sludge Judge
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 at working level. Tank and cover's at 9" below grade. Inlet baffle,outlet tee. No sign of
leakage or over loading.
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•3113 Title 5 Official Inspection Form:S,6surface Sexage Oiaposat System-Page 10 of 17
Vc[L I IJ I I:ocsp P. I I
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner Owner's Name
information
required for every �annisport MA 02647 10-21-13
page. CrtylTown State Zip Code Date of Inspection
D. System Information (cunt.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑concrete ❑metal ❑ fiberglass ❑ polyethylene ❑other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):.
t Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
[Sins•3013 TWe 5 Official Irupecdon Form:SuDsrrrace Sewage Disposal Sys"•Page 11 d 1 T
uct 21 1:5 11:byp P. I L
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner Owner's Dame
information is required for every Hyannisport MA 02647 10-21-13
page. Citylrown State Zip Code Date of Inspection
D. System Information (coat)
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.):
D Box is 16"x16"-29"below grade One line out: Wall's are gone. Need.to replace D Box.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No`
Alarms in wonting 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_
t5irts•3113 Title 5 Official Wpeision Forth:sutmntace Sewage Disposal system.Page 12 of 17 _
Uct'L1 1;3 11:b9p P. 13
S ' Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner Owner's Name
information is Ff annis ort MA 02647 10-21-13
required for every y p
page. Citylrown State Zip Code Date of Inspection
D. System Information (cunt.)
Type:
1
® leaching pits number:
❑ 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.):
leaching is a H 20 1000 Gal. Precast Pit. Pit and cover at 30" below grade. 1"water w/stain line at
around 18" No sign of over loading or solid carry over.
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
161ns-3113 Tito 5 Official Inspection Forth:subsurface Sewage OisposaJ System-Page 13 0117
uct C[ i i[:uua P. I'+
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner Owner's Name
required foon r
Hyannisport MA 02647 10-21=13
required for every
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
15ins•3113 TFUe 5 Official IBpedion Form:Subsurface Sewage Disposal
g posa System•Pa®e 14 or 17
UCI LL 13 l L:UUa P. I O
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner Owner's Name
information is H annis O
required for every Y P rt MA 02647 10-21-13
page. CAY[rown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
R- 3
❑ a 03
Mns-3113 TTW 5 OMOW Inspection Forth:Subsiaram Sewage Disposal System•Page 15 of 17
F
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner Owner's Name
information is required for every Hy
annisport MA _ 02647 10-21-13
page. CitylTown State Zip Code Date of Inspection
D. System Information (cunt_)
Site Exam:
❑ Check Slope
❑ Surface water
❑ Check cellar
❑ Shallow wells
N
Estimated depth tcfh— 12•fgh ground water: feet
Please indicate all methods used to determine the high ground water elevation:
❑ Obtained from system design plans on record
If checked,date of design plan reviewed: Date
® Observed site(abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers -(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
Auger Hole 12' no G.W.. Bottom of it at B'below grade. Bottom of it at 4'above Auger Hole.
9 P 9 P
Before filing this Inspection Report,please see Report Completeness Checklist on next page.
t5irls 3l13 Title 5 Official btspaeNon Forth:SLbsWaea Sewage Dispasal system•Page$6 of 17
r
VCI LL 13 1 L:V la P. I /
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner Owner's Name
information is required for every Hy p annis ort MA 02647 10-21-13
page, Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
(Sins•3113 Tile 5 Official Inspedion Form:Subsurface Sewage Disposal System•Page 17 o(17
14 r, euu.e4.h rNT..,,1,. qY�Ywx^,"f"e.4.1iK"
i
Commonwealth of Massachusetts ~\
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
x.�A.
M s 430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. Citylrown 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: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key goo
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. DOUGLAS A BROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVILLE AAA 02632
City/town State Zip Code
508-4204534 S14297
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
Insp66ors 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.
LZ B20a
t5ins-3113 Title 5 Official Inspection Fo. ub�rface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 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 MET OR EXCEEDED MINIMUM PASSING REQUIREMENTS AT TIME OF INSPECTION
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection ., Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box.,System will
.pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every 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
El ® 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 Y day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
_ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered. A copy of the analysis
and chain of custody must be attached to this form.]
❑ El The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ❑ The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determij a what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility,with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-.Page 5 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
,M 'f 430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no" as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
❑ ® Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
❑ ® Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
- Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information
Description:
1000 GALLON TANK D-BOX AND LEACH PIT
Number of current residents:
Does residence have a garbage grinder? ❑ Yes ❑ No
Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ❑ No
information in this report.)
Laundry system inspected? ❑ Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage(gpd)):
Detail:
2011-107 2012-112 GPD
Sump pump? ❑ Yes ❑ No
Last date of occupancy: Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
� Commonwealth of Massachusetts
Title 5 Official Inspection form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: PRESENT
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ❑ No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13' Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page B of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
�M 430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
1994#94-146
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: .75
feet
Material of construction:
®concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions:
1000 GALLON
Sludge depth:
lot
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
u v Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
< 430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. Cityrrown 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
29"
Scum thickness
1
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
17"
How were dimensions determined?
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 WAS IN WORKING ORDER AT TIME OF INSPECTION
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
�M 430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. City/Town State Zib Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle Condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
i T ght or Holding Tank(tank must be pumped at time of Inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
,Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.)`
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert
0"
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
BOX SHOWED SOME SIGNS OF CORROSION TYPICAL OF ITS AGE BUT WAS FUNCTIONING
PROPERLY AT TIME OF INSPECTION, I HAD DONNA MIRANDI FROM THE BOARD OF HEALTH
TAKE A LOOK AT IT TO CONFIRM MY FINDINGS AND SHE AGREED THAT IT WAS
FUNCTIONING PROPERLY AT THAT TIME
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No*
Alarms in working order: ❑ Yes ❑ No*
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
* If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M , 430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
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
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation; etc.):
PIT HAD @ 1 INCH OF LIQUID AT TIME OF INSPECTION WITH NO SIGNS OF FAILURE OR
OVERFLOW STAIN LINE AT 18 INCHES
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection For
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection-- Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ' 430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
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
430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is HYANNISPORT MA 02647 11/22%13
required for
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
I
® 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
If checked, date of design plan reviewed: Date
❑ Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
PREVIOUS INSP REPORT
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
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M ''p 430 SCUDDER AVE
Property Address
KENT PLUNKETT
Owner Owner's Name
information is required for HYANNISPORT MA 02647 11/22/13
every page. Cityrrown State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems)completed
❑ System Information—Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
-Oct?21312:00a p.15
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
430 Scudder Ave
Property Address
Kent Plunkett
Owner Owners Hame
information is
required for every Ftyannisport MA 02647 10-21-13
Paw. cityirom State Zip Code We of Inspedion
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet Locate
where public water supply enters the building.Check one of the boxes below:
® hand-sketch in the area below
❑ drawing attached separately
A-.�
lg- 3
❑ a- 03
5
Mns•3M3 TWO 5 Olflaal trapeWam Fomt SuWurbw Somps Dbposd Syeam-Pepe 15 or 17
TOWN OF BARNST'ABLE t� /�J�/�' �/
LOCATION �I 30 SEWAGE #'I L4
VILLAGE kIYNNNi.S i�aj ASSESSOR'S MAP & LOTAA" 00
INSTALLER'S NAME & PHONE NO. p.TLl O ContSr Z 36,2- Oq s7
SEPTIC.TANK CAPACITY I000 GPc��.ouS
LEACHING FACILITY:(type)PP-L'CAkS7 P� � # (size) I000&'r ( A6
NO. OF BEDROOMS Z PRIVATE WELL OR PUBLIC W� ATEB
BUILDER OR OWNER 6c)"sr,
DATE PERMIT ISSUED:
DATE COMPLIANCE ISSUED: z s-- 2z'
VARIANCE GRANTED: Yes No
b
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bart^
b v cp
C No.... /0 FRic ......
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Allpfirativit for Bi-nVaiial Works Toutitrurtion ramit
11,V A- is hereby f Pi C
application ereby made a Permit to or Repair an Individual Sewage Disposal
7SMZat:
.......... -f...................................................
ca
tion .
. .. .......
\ _,% %V 14 -
....... ...... ..<..� — .................. ..................................................................................................
Owner Address
-k.:........ ... ............................................
------------------------ ......................................................
Installer Address
Type of Building 4 Size Lot..157.309......Sq. feet
U
Dwelling— No. of Bedrooms- -- ___________________Expansion Attic Garbage Grinder ( )
04 Other—Type of Building ---------------------------- No. of persons-__-_--__-__-_-_-------.--.- Showers Cafeteria ( )
04 Other fixtures;--------...................................................................................................................;:s..................-
Design Flow.........2--b.....Qa.� _3.�......gallons per person per day. Total daily flow. ..........a,ions.
Septic Tank—Liquid capacitv)00.0--gal Ions Length_l�---1�...... Widt0'..1<Z"'___ Diameter................. Depth..§
..............
Disposal Trench—No. .................... Width...._......_._._.... Total Length--__- __-._.__-- Total leaching area...:_._............sq. f t.
Seepage Pit No-------I.......... Diameter.._ .............. Depth below inlet____............. Total leaching area.a.0 ....sq. ft.
Z Other Distribution box (X) Dosing tank ( )
Percolation Test Results Performed by.--__ _S.:-_______________________ Date._.. .......1.4.-Y.7............
Test Pit No. I...�1.........minutesperinch Depth of Test Pit._-- Depth to ground water-----
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water....___.....___.._..__..
------0 -------------------------------------------------- --------------------------------*--------------*..............*.......... --------
Description of Soil.. Q�........ ................................................. ..........t8------ VV\3- r ..........
U .......................................................................................................................................................................................................
.............. ..........................................................................................................................................................................................
U 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 Environmental 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.
Signed ---- A,- -7 - 74.
....... . .... .......................................
Date
Application Approved By ----------------- ........
................***.........................................
Dace
Application Disapproved for the following reasons: ........................................................................................................................................
................................................................................................................................................................................................................ ........................................
Dare
PermitNo. .......... ...... .............. Issued ....................................................................
Dace
___---------------------------- --------------------- --------
No..9� lVZ - R F@$........f �......
<%; a THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
Appliratiun for Diuiauial Eorks Cnunitriirtiun ramit
)pplication is hereby made for a Permit to Construct ( � or Repair ( ) an Individual Sewage Disposal
System at:-7,— ��
--
c.,.y __ l i. ��, e. ........................................
-------------- -
—LJocationn--Address ,yam U or Lot No.
Owner Address
Installer Address _ �'
Type of Building Size Lot__/:5...300s_ .. q. feet
Dwelling—No. of Bedrooms__���:L--------------------Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons............................ Showers ( ) — Cafeteria ( )
0.t Other fixtures ------------------------------ - -
W Desi Flow........ ,_3....Qn. -\. gallons per person per day. Total daily flow....>:Sq�... .��..-- Ions.
WSeptic Tank—Liquid capacityl-Ose.c0--gallons Length 0._�_...... Width �.....__..... Diameter________________ Depth. �.....?......
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No------- ----------- Diameter--- -------------- Depth below inlet................ Total leaching area.P.K AD.....sq. ft.
Z Other Distribution box (x) Dosing tank
'~ Percolation Test Results Performed by..... X`4 5... ..V--y_k....................... Date...f6..-.1. .-. Z...........
,...1 Test Pit No. 1._.� m....______mutesp er mch Depth of Test Pit---- ..... Depth to ground water____
C-14 Test Pit No. 2................minutes per inch Depth of Test Pit-_.--__-----_-_--_- Depth to ground water........................
a ---••-•----------------------•--••••-•---•-•-•----•-•-•-----•-------•-••••--•••-•-----------•-..............................------......--•-----....--------
0 Description of Soil---- 1 {........— --•------- -„---- - .........................rt 5`" .......----
U ...................................................-----------•---•---•--••-•----•-•--------------•------------------------------------•-------------------------------------------.....-•--•--
••-•••---------------------------------------------------------------------------------•----•------•-----•-•---•-----------------------------••---•-•--...•---------•--•----......-•----------•.........
U Nature of Repairs or Alterations—Answer when applicable................................................................................................
........................................-...............................................................................................................................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
J the provisions of TITLE 5 of the State Environmental 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.
M' Signed .... --�` -...Z-... - ,e. .... 4- 4 — 74
.......... .... ..................
Dace
Application Approved By ----------------- ...... .. ... /./ -
Application Disapproved for the following reasons: ............. ............_ . ......_........... ... .. --- ................ . . ..........
.... .. ........................................
.........--....... ................................................................----� Dare
Permit No. ---------!.- �..y�.............. Issued ................... Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE
(fickifirate of C omplianre
THIS IS TO G--RTIFY, That the Individual Sewage Disposal System constructed ( ) or Repaired ( )
b �'� - .... - - -
Y ------------------
Insrdler
at �3-----
has - - - --e-1- s-' ..........C( ............................................ --------------------------------------------------------------------------
.. . ..
been installed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in
the application for Disposal Works Construction Permit No. -------�.y-......1.. �------ dated -------.------------------------------........
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE - Ile,
------ Inspector
ector
--------. ---
THE ........ �..... .... ......
COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
TOWN OF BARNSTABLE / 0 ,FEE........................
deposal Worb Tnntrution rrrntit
Permissionis hereby granted--------- " -----•----------------------------------------------------------------------------------•-------•----------------
to ,C�i t �) or Repair ( ) an Individual Sewage Disposal System ,
at1`'1°•-�T ` 9--. •-----... ''e%--pr�.. - ---(--(�7.-•-••-•--------.... �ce=..�- -------------------------------------------•---.............
Street y+
as shown on the application for Disposal Works Construction Permit No../.-�.���. Dated...........................................
Boa of Health ,�y�rd
DATE............................-------•-- --------7C-----�----•-------------•-•----
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Page 1 of 1
TOWN OF BARNSTABLE u r
LOCATION Z{ a>O ScvUDS2 SEWAGE # '9 L4 _ I
VILLAGE ily^NlJ►S F69-T ASSESSOR'S MAP & LOTA21fe'
INSTALLER'S NAME & PHONE NO. D,T"f-�o Cot.-is 36,2_ W-
SEPTIC TANK CAPACITY 1000 GPcU_oNs
LEACHING FACILITY:(type)PP-E'C NG7 p%T (size) 1000 6
NO. OF BEDROOMS Z PRIVATE WELL OR PUBLIC WATER
BUILDER OR OWNER -D• TH-I F-o
DATE PERMIT ISSUED: 1` ,t -/ & 4
DATE COMPLIANCE ISSUED• '
VARIANCE GRANTED: Yes No C!
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http://issgl2/intranet/propdata/prebuilt.aspx?mappar=288009&seq=2 9/30/2013