Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
0023 SECURITY STREET - Health
23 Security Street,Hyannis � �t No. Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: Y PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS es ZippYitation for Disposal 6psteut Construction Permit Application for a Permit to Construct( ) Repair(/Upgrade( ) Abandon( ) [:]Complete System Individual Components Location Address or Lot No. � e Owner's Name,Address,and Tel.No. Assessor's Map/Parcel 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 No.No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) ,x 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 He Signed Date Application Approved by Date Application Disapproved by Date for the following reasons Permit No. O Date Issued 1 V No. ( ; Fee THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: PUBLIC HEALTH DIVISION - TOWN OF B RNSTABLE, MASSACHUSETTS Yes Yltatlon for Mls osal 6pstfm Construction Permit Application for a Permit to Construct( ) Repair V4/upgrade( ) Abandon( ) El Complete System Individual Components Location Address or Lot No..23 V'-c 6w,TSp GP Owner's'Name,Address,and Tel.No. w���Assessor's Map/Parcel R6 //00 �`''y w 790 — �yy� Installer's Name,Address,and Tel.No. Designer's Name,Address,and Tel.No. Type of Building: Dwelling No.of Bedrooms 3 Lot Size sq.ft. Garbage Grinder( ) Other Type of Building ���� No.of Persons Showers( ) Cafeteria( ) Other Fixtures Design Flow(min.required) gpd Design flow provided gpd Plan Date Number of sheets Revision Date Title Size of Septic Tank Type of S.A.S. Description of Soil Nature of Repairs or Alterations(Answer when applicable) �°�'"�,,��G G� •t*- %6'® X 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 t A: Compliance has been issued by this Board of He Signed Date Application Approved by Date /(� 3 � , Application Disapproved by Date for the following reasons Permit No. �� '— .. Date Issued 3 - ----------------------------------------------------------------- --- THE COMMONWEALTH OF MASSACHUSETTS BARNSTABLE, MASSACHUSETTS Certificate of Compliance THIS IS TO CERTIFY,that the On-site Sewage Disposal system Constructed( ) Repaired( ") Upgraded( ) Abandoned( )by ��n'I ��O�y�� J IC J'G/C . at .Z f'c�f"�4t/T% / ✓tidy has been constructed in accordance with the provisions of Title 5 and the for Disposal System Construction Permit No:�)O/ 'l�(o dated G /73 h Installer ���'1 G cZ"�o�v Designer #bedrooms ° +b" "OX 0�''L�= Approved design floyv gpd The issuance of Tis shall not be construed as a guarantee that the system w C iJon as designed.Date 3ieT Inspector / ----- --------�V---���lD---------------------------------------- -------------------- -----------=--=- -- =---- 5-------- No. Fee 7 THE COMMONWEALTH OF MASSACHUSETTS PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS Misposal 6 ste Construction Permit Permission is hereby granted to Construct( ) Repair( Upgrade( ) Abandon( ) System located at G'�����✓ /7��° and as described in the above Application for Disposal System Construction Permit. The applicant recognized his/her duty to comply with Title 5 and the following local provisions or special conditions. Provided:Constructio must b completed within three years of the date of this pe it. Date > � / Approved by AsBuilt Page 1 of 1 G : TOWN OF BARNSTABLE LOCATION iR 3 S C !/4/ T�/ SEWAGE # VILLAGE s ASS ESSOR-S MAP & LOT�`� INSTALLER'S NAME & PHONE NO. ,1 /� A A C- 0 M ,B&A r S®A/. SEPTIC TANK CAPACITY_ / D D D LEACHING FACILITY:(tgpe)_p/,r (size) /• O O y NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER d DATE PERMIT ISSUED: i DATE COMPLIANCE ISSUED: 7 - 1 �4 VARIANCE GRANTED: Yes _ No_ � y o http://issgl2/intranet/propdata/prebuilt.aspx?mappar=268118&seq=1 6/3/2016 T Commonwealth of Massachusetts W Title 5 Official Inspection Form ?�N Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Security Z y Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every H annis � MA 02601 June 3 2016 y page. City/Town State Zip Code Date of Inspection ... N. Inspection results must be submitted on this form. Inspection forms may not be altered in any Y way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, use only the tab 1. Inspector: key to move your cursor-do not David B. Mason use the return Name of Inspector key. David Mason Company Name 4 Glacier Path Company Address East Sandwich MA 02537 City/Town State Zip Code 508-367-1617 S1287 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 —.--,®r-IR A June 3, 2016 Inspector's Signatu e •. '"� Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface.Sewage Disposal System Form - Not for Voluntary Assessments 23 Security Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 page. Cityfrown 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: This inspection represents the condition of the system observed for the moment on Friday, June 3, 2016 at 4:34 PM and does not guarantee the continued operation of the system from.this date forward. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �M 23 Security Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 page. City/Town 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 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ° 23 Security Street M Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 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 cesspool is less than 6" below invert or available volume is less than Y2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Security Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone 11 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 w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Security Street M Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 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•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °1M 23 Security Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 page. Cityfrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: 2 Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include.laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ® No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: 2014; 25,500 gallons and 2015;24,000 gallons Sump pump? ❑ Yes ® No Last date of occupancy: current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ® No Industrial waste holding tank present? ❑ Yes ® No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ® No Water meter readings, if available: t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 'wM 23 Security Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Board of Health Was system pumped as part of the inspection? ❑ Yes ® No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Security Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 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: Installed July 12, 1994 Were sewage odors detected when arriving at the site? ❑ Yes ® .No Building Sewer(locate on site plan): Depth below grade: 3 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other(explain): Distance from private water supply well or suction line: 10+feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): Depth below grade: 2 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 Typical Sludge depth: 2" t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M 23 Security Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 36" 2" Scum thickness Distance from top of scum to top of outlet tee or baffle 3" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Scour Stick Comments (on pumping recommendations,-inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Effluent level with outlet invert. Tank is 23 inches below grade. 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 w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 23 Security Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 page. City[Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of Massachusetts w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments °wM 23 Security Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box (if present must be opened) (locate on site plan): Depth of liquid level above outlet invert liquid level with outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): no indication of solids carryover. H2O dbox. 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 w Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments c,M 23 Security Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 page. City/Town 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.): 6 foot pit with 2' stone. effluent is 39" below inlet invert. No indication of staining above that. 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Security Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 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.): t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Security Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M 23 Security Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ❑ Shallow wells Estimated depth to high ground water: 18 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: Groundwater Contour Map ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Groundwater Contour Map I 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 W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ^M 23 Security Street Property Address Michael and Maureen Webb Owner Owner's Name information is required for every Hyannis MA 02601 June 3 2016 page. CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked E Inspection Summary D (System Failure Criteria Applicable to All Systems) completed E System Information— Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•3/13 Title 5 Official Inspection Form:Subsirface Sewage Disposal System•Page 17 of 17 f Assessing As-Built Cards Page 1 of 2 CA ; TOWN OF BARNSTABLE LOCATION A 3 S c C u x SEWAGE ` F0 VILLAGE h,�,�/J S ASSESSOR'S MAP & LOT_2_61, /S INSTALLER'S NAME & PHONE NO. A L oAt ,Ber( Y. SBy SEPTIC TANK CAPACITY 0 0 D LEACHING FACILITY:(type) (size) A 0 0 f) NO.OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER r►�, ,,, DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No ems, ry 0 http://www.townofbamstable.us/Assessing/HMdisplay.asp?mappar=268118&seq=1 6/6/2016 Commonwealth of Massachusetts r; Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assess 1" s 9 P Y ry \C s 23 Security Road Property Address Mike Webb Owner Owner's Name information is H required for Y annis MA 02601 1/8/2013 every page. City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out A. General Information forms on the computer,use 1. Inspector: \I �1/- only the tab key �" (n ` to move your Wayne Archambeault "`. cursor-do not use the return Name of Inspector w key. t 5� "— Company Name ` fl ; e « box 914 Company Address Hyannis MA02601 . Cityrrown State Zip Code 508-775-1362 355 Telephone Number License Number +fl M 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 Apprt�rfg Authority i 1/8/2013 Inspector's Signature- - Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. 15ms•11110 Title loffict ns?tion Subsurface Sewage Disposal System•Page 1 of 17 �'- Commonwealth of Massachusetts w rye Title 5 Official Inspection Form ?V, ,h.; Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Security Road Property Address Mike Webb Owner Owner's Name information is required for Hyannis MA 02601 1/8/2013 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E /always complete all of Section D A) System Passes: ® 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) 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•11110 Title 5 official Inspection form.Subsurface Sewage Disposal System•Page 2 of 17 r ' .. Commonwealth of Massachusetts a Title 5 Official Inspection Form i^'• Vim!...1 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Security Road Property Address Mike Webb Owner Owner's Name information is Hyannis MA 02601 1/8/2013 required for y every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) 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•11110 Title 5 official Inspection Form Subsurface Sewage Disposal system•Page 3 of 17 Commonwealth of Massachusetts -- Title 5 Official Inspection Form U` Subsurface Sewage Disposal System Form Not for Voluntary Assessments 23 Security Road Property Address Mike Webb Owner Owner's Name information is Hyannis MA 02601 1/8/2013 required for y every page. CitylTown 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 El ® 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 Title 5 off iciai Inspection Form.Subsurface Sewage Disposal system•Page 4 of 17 t5ins 11110 t 'fir Commonwealth of Massachusetts Title 5 Official Inspection Form imp I='i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 23 Security Road Property Address Mike Webb Owner Owner's Name information is required for Hyannis MA 02601 1/8/2013 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified. laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA) or a mapped Zone II of a public water supply well If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CM 15.304. The system owner should contact the appropriate regional office of the Department. Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 5 of 17 t51ns•11110 i Commonwealth of Massachusetts Title 5 Official Inspection Form m' II' Subsurface Sewage Disposal System Form - Not for Voluntary Assessments C 23 Security Road Property Address Mike Webb Owner Owner's Name information is Hyannis MA 02601 1/8/2013 required for y every page. CitylTown 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 ® El 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 I t5ins•11110 Title 5 Official Inspection Form Subsurface Sewage Disposal system•Page 6 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form !` N Subsurface Sewage Disposal System Form Not for Voluntary Assessments 23 Security Road Property Address Mike Webb Owner Owner's Name information is required for Hyannis MA 02601 1/8/2013 every page. Cityfrown State Zip Code Date of Inspection D. System Information Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes E No Water meter readings, if available (last 2 years usage (gpd)): Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Date P Y� 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 k Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: _. __.._.. .__ _... ....... .... ..... ..... t5ins 11110 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts _ rb Title 5 Official Inspection Form 1� - iTi ;y Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Security Road Property Address Mike Webb Owner Owner's Name information is Hyannis MA 02601 1/8/2013 required for y every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: -......_._....--------........__._._.__.._..........._............._... ..._._..._... .. Date Other(describe below): General Information Pumping Records: owner 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 i ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 8 of 17 51ns•11110 Commonwealth of Massachusetts tmi Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 23 Security Road Property Address Mike Webb Owner Owner's Name information is required for Hyannis MA 02601 1/8/2013 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: installed 7/12/1994 permit#94-380 Were sewage odors detected when arriving at the site? ❑ Yes ❑ No Building Sewer(locate on site plan): 1' Depth below grade: feet Material of construction: ® cast iron ❑ 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): Septic Tank (locate on site plan): 1' 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 8:5'x5'x5' -- -- —.- - — ---- Dimensions: 3" Sludge depth: t5ins•11/10 Title 5 official Inspection Form Subsurface Sewage Disposal System•Page 9 of 17 y ` Commonwealth of Massachusetts Title 5 Official Inspection Form iT' M Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Security Road Property Address Mike Webb Owner Owner's Name information is required for Hyannis MA 02601 1/8/2013 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 34" 2., Scum thickness _.._..._ ._.---.---......... __._-._... . ._..----__.._-_..-- 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 13" How were dimensions determined? measuring rod 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 structuraly sound liquid level at proper heights 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 y E l5ins•11110 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 23 Security Road Property Address Mike Webb Owner Owner's Name information is required for Hyannis MA 02601 1/8/2013 every page. CitylTown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Dace Comments (condition of alarm and float switches, etc.): 's F i( S f Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No i i5ins.11110 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 tti 'uR Commonwealth of Massachusetts 3� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Security Road Property Address Mike Webb Owner Owner's Name information is Fi required for Y annis MA 02601 1/8/2013 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 level and water tight 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.): Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: 15ins•11/10 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 23 Security Road Property Address Mike Webb Owner Owner's Name information is required for Hyannis MA 02601 1/8/2013 every page. CityfTown 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.): 1 6x6 1000 gallon precast leaching pit liquid level 3'6" below invert stain line 2'6" below invert 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 t51ns•11110 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form M Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Security Road Property Address Mike Webb Owner Owner's Name information is required for Hyannis MA 02601 1/8/2013 every page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•11/10 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 14 of 17 L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 23 Security Road Property Address Mike Webb Owner Owner's Name information is required for Hyannis MA . 02601 1/8/2013 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately I t5ins•11/10 Title 5 Official Inspection Form.Subsurface Sewage Disposal System•Page 15 of 17 Assessing As-Built Cards 1/8/13 8:55 PM TOWN OF BARNSTABLE LOCATION A 9 S c G U/t'/ T SEWAGE # VILLAGE S ASSESSOR'S MAP & LOT__-) Il INSTALLER'S NAME & PHONE NO. ,T P A A C 0A4 0e,r; rt ceAl SEPTIC TANK CAPACITY LEACHING FACILITY:(type) (size) /• a 0 v NO. OF BEDROOMS 3 PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: _ V DATE COMPLIANCE ISSUED: y i I VARIANCE GRANTED: Yes No i I I ems, � I �r, s � yy 0 http://www.town.barnstable.ma.us/Assessing/HMdisplay.asp?mappar=268118&seq=1 Page 1 of 2 Commonwealth of Massachusetts �r� Title 5 Official Inspection Form !l Subsurface Sewage Disposal System Form - Not for Voluntary Assessments — 23 Security Road Property Address Mike Webb Owner Owner's Name information is required for Hyannis MA 02601 1/8/2013 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells Estimated depth to high ground water: 15' 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: town GIS maps ❑ Checked with local excavators, installers- (attach documentation) ❑ Accessed USGS database -explain: You must describe how you established the high ground water elevation: Barnstable GIS 15' bottom of SAS 8' seperation 7' ...._................__._.._... _..... -.. ........__......_..............:.. . ...._.._... .... _..__.._.. _.. .__... - -- ..._ . ..... — ... ---- Before filing this Inspection Report, please see Report Completeness Checklist on next page. 15ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 4 Commonwealth of Massachusetts . yam\ ^ � Title 5 Official Inspection Form 51 Subsurface Sewage Disposal System Form - Not for Voluntary Assessments \x 23 Security Road Property Address Mike Webb Owner Owner's Name information is required for Hyannis MA 02601 1/8/2013 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 15,ns•11110 Title 5 Official Inspection Form Subsurface Sewage Disposal System•Page 17 of 17 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS _ DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617.292.5500 WILLIAN1 F.WELD i 'Rl`D1'CO Govcmor Q air Sc;rct ARGEO PAUL CELLUCCI 4 DAVIDIB STRU Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTIONJORMjO'NNop. 1998 rCjNcommissio PART A q�rti FajrABiE CERTIFICATION \ Property Address:23 Security Street Hyannis MA Address of Owner: 144,,. .of=de.n Heil :�lSt . Date of Inspection: 2/1 3/9 8 (If different) Br idgeport,-Conn. Name of Inspector: ,joseph P.Macomber Jr. 06604 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: J.P.Macomber & Son Inc. Mailing Address: Rnx 66 (,pnfiPryi 1 1 P',Ma-;-; - 02632 Telephone Number: 59�77a-33�$ CERTIFICATION STATEMENT I cenify that I have personally inspected the sewage disposal system at this address and that the information reported below is vue, accurate and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: ZPasses 1 Conditionally Passes — Needs Further Evalyon By the Local Approving Authority Fails �J ( Inspector's Signature: 44 Date: The System Inspectordlbmit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owne and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, Or D: A) SYSTEM PASSES: \ > I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303, Any failure criteria not evaluated are indicated below. COMMENTS: BI SYSTEM CONDITIONALLY PASSES: V One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upol completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes. no, or not determined (Y, N, or ND). 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 (attached) indicating that the tank was installed within twenty (20) 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. (revised 04/25/97) Page 1 of 10 DEP on the World Wide Web: http:/Ayww,magnet.state.ma.us/cep + Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 23 Security Street Hyannis,Mass . Owner: Ira Charmory Date of Inspection:2/13/98 B) SYSTEM CONDITIONALLY PASSES (continued) 12 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four 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 C) FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: A)D Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: A/4' Cesspool or privy is within 50 feet of a surface water O Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: d6 The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary 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 supply well. ALr The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. A The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a private water supply well, unless 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 A)/)f (approximation not valid). 3) OTHER (revised 04/25/97) Page 2 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 23 Security Street Hyannis,Mass . Owner: Ira Charmory Date of Inspection: 2/1 3/9 8 D) SYSTEM FAILS: You must indicate ewer "Yes" or "No" as to each of the following: A/6_ i have determined that the system violates one or more of the following failure criteria as defined in 310 CN1R 15.303 Tne bass: for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to corm the failure. Yes NO Backup of sewage into facility or system component due to an 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 o, cesspool. Static liquid level in th distrib ion box abo a outlet inven due to an overloaded or clogged SAS or cesspool Liquid depth in ee9speel—+s less than 6" below inven or available volume is less than 1/2 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped LWle Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with r acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis is coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: You must indicate either "Yes" or "No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: /01 The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: Yes No ltll¢ 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 facility into full compliance with the groundwater treatment prograrr requirements of 314 CMR 5.00 and 6,00. Please consult the local regional office of the Department for further information (revised 04/25/S7) Page 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 23 Security Street Hyannis,Mass. Owner: Ira Charmory Date of Inspection: 2/1 3/98 Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No , Pumping information was provided by the owner, occupant, or Board of Health. None of the system components have been pumped (or 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 obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. _ All system components, 4eluding the Soil Absorption System, have been located on the site. 4 _ The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of / Sub-Surface Disposal System. Existing information. Ex. Plan at B.O.H. _ Determined in the field (if any of the failure criteria related to Pan C is at issue, approximation of distance is unacceptable) (15.302(3)(b)] (revised 04/25/97) U&q• 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 23 Security Street Hyannis,Mass. Owner: Ira Charmory Date of Inspection:2/1 3/9 8 FLOW CONDITIONS RESIDENTIAL: Design flow: 3'6 p.d./bedroom for S.A.S. Number of bedrooms: ':� Number of current residents:" Garbage grinder (yes or no): VP } Laundry connected to system (yes or no): s ccA�h .C'S P-IJ Seasonal use (yes or no):�' Water meter readings, if available (last two (2) year usage (gpd): 1�/C���- '�� cllsel Sump Pump (yes or no): .!>D Last date of occupancy: 4wkll COMMERCIAUINDUSTRIAL: Type of establishment: 4)14 Design flow: A)R eallons/day Grease trap present: (yes or no)A)A Industrial Waste Holding Tank present: (yes or no)—ii-19 Non-sanitary waste discharged to the Title 5 system: (yes or no)N4 Water meter readings, if available:)!} lu it Last date of occupancy: OTHER: (Describe) A)a Last date of occupancy: AJ GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no) If yes, volume pumped: gallons Reason for pumping: IUff TYPE OF TEM Septic tank/distribution box/soil absorption system k'o _ Single cesspool A10 Overflow cesspool Privy ,t10 Shared system (yes or no) (if yes, attach previous inspection records, if any) AIA I/A Technology etc. Copy of up to date contract? Other AJ1 APPROXIMATE AGE of all components, date install (if known) and source of information: — .y s j� '7-.1 �ip'z,� ��1—S�'o a.�;� �9,��n�►a0�e:^ ,� ��� �y�. i Sewage odors detected when arriving at the site: (yes or no)&a (revised 04/25/97) Pago 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 23 Security Street Hyannis,Mass. Owner: Ira Charmory Date of Inspection: 2/13/98 BUILDING SEWER: (Locate on site plan) Depth below grade: > ' Material of construction: _cast iron Z40 PVC _ other (explain) Distance from/private water supply well or suction line —1 _ Diameter ` 1 Comments: (condition of joints, ve ting, evidence of leakage, etc.) SEPTIC TANK:,�2CV���✓ 4a 3; (locate on site plan) Depth below grade: Material of construction: concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age tV01 Is age confirmed by Certificate lo_f1 Compliance 'CIA(Yes/No) Dimensions: Sludge depth: �- Distance from top�ludge to bonom of outlet tee or baffle, 6-/—)VL Scum thickness: Distance from top of scum to top of outlet tee or baffler Distance from bottom of scum to bonom of outlet tee or baffle How dimensions were determined: �¢5�12°�/. Comments: (recommendation for pumping, conditio I of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural inLe rit), evidence of leakage, etc.) �W ' , T ' .J r/f� i J` a• � .J i �9 GREASE TRAP�ifIe (locate on site plan) Depth below grader Material of construction AJAoncreteNAmetaIAWFiberglass444Polyethylene4/Mother(explain) 'V11V Dimensions: .4)4 Scum thickness: .r✓.q Distance from top of scum to top of outlet tee or baffle�-A/,4t Distance from bottom of scum to bottom of outlet tee or baffle:- Date of last pumping: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.( 10, (revisal 04/25/97) P.g. 6 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 23 Security Street Hyannis,Mass . Owner: Ira Charmory Date of Inspection: 2 1 3 9 8 TIGHT OR HOLDING TANKVVV4,(Tank must be pumped pnor to, or at time, of inspection) (locate on site plan) Depth below grader Material of con struaion;jconcretewAmetak/&FiberglassVAPolyethylene.vdother(explain) A)h A2A Dimensions: .414 Capacrry: 4-1A gallons Design flog.: A,,l gallons/day Alarm level.— IV/¢ Alarm in working order.).¢ Yes: C),a Nu Date of previous pumping: A( ,4. Comments (condition of inlet tee, condition of alarm and float switches, etc.) 51 DISTRIBUTION BOX:�� (locate on site plan) Depth o- licuid level above outlet invert: f S_ Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) & Tr- 1.04 i PUMP CHAMBER:AQye (locate on s;te plan) Pumps in working order: (Yes or No) 410 Alarms in �,orking order (Yes or No)_l� Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (rsvis•G 04/25/97) P-g. 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 23 Security Street Hyannis,Mass . Owner: Ira Charmory Date of Inspection: 2/1 3/98 SOIL ABSORPTION SYSTEM (SAS):LArp'_d4/P4.'4&� XT (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number: leaching chambers, number: leaching galleries, number:= leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: luh C Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of onding, condition of vegetation, etc.) 02, CESSPOOLS: (locate on site plan) Number and configuration: / Depth-top of liquid to inlet invert: A14 Depth of solids layer: Depth of scum layer. Dimensions of cesspool: Materials of construction: Indication of groundwater: /V inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: 2,6ve__ (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.) e (revls*d 04/25/97) aag. 8 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 23 Security Street Hyannis,Mass. Owner: Ira Charmory Date of Inspection: 2/1 3/98 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) a3 5 f (Icknolus 14 10' tt \C (revised 04/25/97) Page 9 of 10 v SUBSURFACE SEWAGE DISP,. ! SYSTEM INSPECTION FORM I . C SYSTEM INFOI: .. !ION (continued) Property Address: 23 Security Street Hyannis,Mass. Owner: Ira Charmory Date of Inspection: 2/1 3/98 Depth to Groundwater 45—�Feet Please indicate all the methods used to determine High Groundwater Fle.a:ion: Obtained from Design Plans on record Observation of Site (Abutting property, observation hole, basemtni-s,mp etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps /Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Ground.+a?ef-Elevation. Must be completed) Used Water contours Map. Gahrety & Miller Model 12/16/94 (revix•Z 04/25/97) Pac, of 10 t*nr+,—n+rr—.-rr— nrrmr•nmrr�+nre*r.rn.+s:-.'se+erv.r:ter.-n-n*n esr�,sa r.cvn.rss+ �-,i.;-z.rn.rn.Tr_�_ _ _ t' TOWN OF Barnstable BOARD OF HEALTH 11� SUIISURFACF SEWAOF DISPOSAL SYSTEM INSPECTION FORM - PART U - CERTIFICATION `� 1`•••�.•.�T••.••.. -�.I IT rr.T.T.11•T'1TITTFT11tTT.T'.r-!.'I."'llTl•R^l 91•RAf"�7Y T1 RTII•TRTi"RRTTRTf.��.•.:rr� T•�. +. -TYPE OR PRINT CI.EARL1'- PROPERTY INSPECTED STREET ADDRESS 23 Security Street Hyannis,Mass . ' ASSESSORS MAP, BLOCK AND PARCEL d 3 OWNER' s NAME Ira Charmory PART D - CERTIFICATION I NAME OF INSPECTOR Joseph P.Macomber Jr. COMPANY NAME J.P.Macomber & "A Inc. COMPANY ADDRESS Box 66 Centerville,Mass. 02632 Street Town or City State LIP COMPANY TELEPHONE ( 508 ) 775 - 3338 FAX ( 508 1 790 -1578 •t CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true , accurate , and complete as of the time ofiinspection . The inspection was performed and any recommendations regarding upgrade , maintenance , and repair are consistent with my training and experience in the proper function and maintenance of on- site sewage disposal systems . Check one : _ ' System PASSED The inspection which I have conducted has not found any information which indicates that the system fails to adequately protect public heaiLh or, the environment as defined in 310 CMR 15 . 303 , Any faililre criteria not evaluated are as stated in the FAILURE CRITERIA section of this form . System FAILED* The inspection which I have con lcted has found that the system fails to Protect the 'public health and the environment in accordance with Title 6 , 310 CMR 15 , 303 , and as specifically noted on PART C - FAILURE CRITERIA of this inspection for Inspector Signature IL Date One copy of this certification must be provided to the OWNER, the BUYER ( where applicable ) and the DOARD OF HEAL1'JI. * If the inspection FAILED, the owner or operator shall upgrade the system within one year of the date of the inspection , unless allowed or required otherwise as provided in 3.10 CMR 15 , 305 , partd .doc Ld 4 U) v ti THE C OMMON VWALTH OF MA.SSA CHUSETTS DEPARTM ENT OF ENVZRONNEENTAL PROTECTION BE IT KNOWN THAT Joseph P. Macomber, Jr. Has satisfied the Department's qualificatiqns as required uired and is hereby authorized to use the title CERT { i D TITLES SYSTEM INSPECTOR as provided in 310 CMR 15.340 and Section 13 of Chapter 21A of the General Laws. Issued by The Department of Environmental Protection. )u� a. 199s _ - Acting Director of the i ion u( W11er Pollution Control G , TOWN OF BARNSTABLE ,LOCATION A 3 S e C U tt/� SEWAGE # VILLAGE Hve AAIAIl ASSESSOR'S MAP & LOT INSTALLER'S NAME & PHONE NO. f /° 1M A C O tit e eX -- S 9N SEPTIC TANK CAPACITY A Q p d LEACHING FACILITY:(type) /p/, (size) J' O O C) NO. OF BEDROOMS PRIVATE WELL OR PUBLIC WATER BUILDER OR OWNER DATE PERMIT ISSUED: DATE COMPLIANCE ISSUED: VARIANCE GRANTED: Yes No L/ � � �� � 1 1� � � � � � 3W �o ��, �o. �-. � � ��'J o - �, 6- �� s I� i w �r j Fizic.............(i/0 0 i. ... N � E�~��'COMMONWEALTH OF MASSACHUSETTS � ^k,� i1 BOARD OF HEALTH Signed Da'GroWN OF BARNSTABLE Appliration for Divjipwial Works Tomitrnrtinn jJamit Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage,Disposal System at: 23 Security Road Hyannis ............................"-".............."-""-""--"".....----""............................... ............---.......---•......--------.........................----........------...--------.-- Location-Address or Lot No. Charmoy ......................--.......................................................................... -•-•-••-----------•-•-----...........................-----.............---.....--•---------....... Owner Address a J-P.-Maco-mbar---- ----------------------------------------------•-------••-•---------------------------•----..-•---- Installer Address d Type of Building Size Lot............................Sq. feet V Dwelling-X No. of Bedrooms................. ......----.-.-------_---Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ---------------------------- No. of persons.....--....--.--............ Showers ( ) — Cafeteria ( ) a Other fixtures ------------------------------ W Design Flow............................................gallons per person per day. Total daily flow................................... .gallons. WSeptic Tank—Liquid capacity------------gallons Length---------------- Width................ Diameter..---I.......... Depth---.---.--...... x Disposal Trench—No. ------..-_--------. Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter......-..--------.-. Depth below inlet..--................ Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) 0-4 Percolation Test Results Performed by.......................................................................... Date........................................ aTest Pit No. l----------------minutes per inch Depth of Test Pit.................... Depth to ground water.........--............. f� Test Pit No. 2................minutes per inch Depth of Test Pit............---..... Depth to ground water............--.......... --------"--------------------"--"-----------""--"-----------------------•-•-----.............................................••-•-.......................---- 0 Description of Soil----------------------------------------------------------------------------------------------------------------------------------------------------------------------- W Sand & Gravel U W •-------------------- -- ------------ -------------------------------------------------------------------------- x Omit cesspooYs . Iiisl;�al-1....""""""" V Nature of Repairs or Alterations—Answer when applicable------------------------------------ -- - .-.----.--- 1-1000 gallon tank 1-distribution boix 1-1000 gallon leac pit . 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 Compliant has b e is ed b he boa-d of ealth. Signed ........ . .. .... . . .�..... :... 0,... ..::.._...............---- ---71.121.9.4:.....:...... Dare Application Approved By ........ ........ ...... .. ........ .......... ........ . ..... .......................... .. ..................................... -----------'--Dace----------...... Application Disapproved for the following reaso s. ......................................................................................... ... ................................. .................. ..... .... .. .. .. -----......---------------------------------......---------- .................... ------------------- .............. Permit No. .. ......................... Issued ........... -.. ..------ ate...... l are 1 F $ 3©/00 No.._.. ps.............................. THE COMMONWEALTH OF MASSACHUSETTS 11BOARD OF HEALTH ` TOWN OF BARNSTABLE 1 Appliration for Diti-po Sal Works Tonotrnrtion Urrmit Application is hereby made for a Permit to Construct ( ) or Repair (XX) an Individual Sewage Disposal System at: 23 Security Road Hyannis ...................•-•--...•---•----•-----••-•••.....---•--•-•---............-•----........._-•••- ---•-----•--•-----••----•--•-••--•••-----•--._..__.....----••----•-------•---•-••--•-••---•-•--... Location-Address or Lot No. Charmoy Owner Address aD M ai jo e .... ---•------------------"------------------ --•-.............................................................................................. Installer Address UType of Building Size Lot............................Sq. feet Dwelling X No. of Bedrooms________________3____-___---_-___---._-...Expansion Attic ( ) Garbage Grinder ( ) aOther—Type of Building ____________________________ No. of persons---------------------------- Showers ( ) — Cafeteria ( ) a' Other fixtures _______________________________ __ W Design Flow............................................gallons per person per day. Total daily flow............................................gallons. WSeptic Tank—Liquid capacity____-_.__-_gallons Length________________ Width................ Diameter................ Depth................ x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft. Seepage Pit No..................... Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft. Z Other Distribution box ( ) Dosing tank ( ) aPercolation Test Results Performed by.......................................................................... Date.--"-""""----........................... Test Pit No. 1................minutes per inch Depth of Test Pit-................... Depth to ground water..................... (i Test Pit No. 2................minutes per inch Depth of Test Pit-------------------- Depth to ground water........................ R', ._...-•-••----------------------------------------------•"..............•-•-•••••--•......-•----....._........._._.....•-•..... -....... ODescription of Soil-"""""-"-""•"----"----"-"""-""""""""""""""-""--"----""....._............................................................................................................ x Sand & Gravel V ...••-•••..........•-------•••••---•.............................•-••-•-•---••-•••------......---•--••••••--•------------------•------.._.....••---•...-••----------•-•-•--••-•........................_ W ••••.......................................................•------------------------------------------------------ x Omit cesspools:""""Trigt'aI-2•----•-"•-••"--- Natu a Re airs or Alterations—Answer hen lic ble........ ..... . .____-_._-__-----........_..__....,_......4..... .................... U i-10 0 gallon tank 1-di oix 1-1I gallon lead pit . ............................... 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 Compliant has b e �is/s ed b the boa,d of health. 1 . . ... ---------------------------------------- Date7/12/94 Signed .........:....... ....::.. ..... ..._. .... ..-...•..........-....... /` � � ! /` / f 1_ f---''---------------- Application Approved By .-.. � � ..�..�:... - �'3, ' -• .�'t-:�:.f.......:....-- .--�-- - .................................. Dare Application Disapproved for the following reasons..,*------------- ---------------------------------------------------------------------------------------------------------------------- ------- nt......./........-- ^^.... ----------------------------- - .............. Permit No. .............................h...:.? �..... ...... Issued ...........:./ . 1 J.---.------ ------ all! � _ dare � j. THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH TOWN OF BARNSTABLE 01rlrtif rate of C�omplianre THIS 1 TO RTIF That the Individual Sewage Disposal System constructed �, ) or Repaired ( XXX) J .P.r acomnb . by ............. ....................... ........-.. ................................... .............. ...................................................... .......... . ............................... Installer 23 Security Road Hyannis at ......... ........................... ................... ------ has .............. ...... been installed in accordance with the provisions of TITLE SRof�The State.Environmental Code as described in the application for Disposal Works Construction Permit No. _f." .............. _�'� !.... dated ........._...........-__............_...... THE ISSUANCE OF THIS CERTIFICATE SHALL NOT IiE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION SATISFACTORY. / [ . .... .. ....... ............... Inspector ...-.... - DATE-------- ------------7--------- CJ THE COMMONWEALTH OF MASSACHUSETTS / BOARD OF HEALTH TOWN OF BARNSTABLE $ 30.00 --� i FEE............. Disposal Works Tonstrudion "rrmit j J.P.Macomber Jr . Permissionis hereby granted.............................................................................................................................................. to Const uct ( or,Re a rX X) n Individual Sewage Disposal System �3 Securit� rho d Hyannis at No..................... - - - --------- - --- - - - - -----•--•-------------- -.........................."------•------•--•------•-••-...................-- -- yyy " - Works t Street �� as shown on the application for Disposal orks Construction Permit No.............. .....jDated____.--_--._.._.__. ..................... Jf f . � __ l:-- �:�1-c r/ ------------------ Gj Board(of Health DATE..................... fI , r ............................ FORM 36508 HOBBS&WARREN.INC..PUBLISHERS