HomeMy WebLinkAbout0079 SEVENTH AVENUE (HYANNIS) - Health 79 SEVENTH AVE., HVANNISPORT
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Commonwealth of Massachusetts
Title S Officiat Inspection Form
Subsurfi3ce'Sewage Disposal System ftrm-Not for Voluntary Assessments
797"Avenue
Property Address
Stephen Corridan
Owner Owner's Name
information is
required for every West Hyannisport MA 02672: 03/17/12
page. Cityfrown state Zip'Code Date of Inspection
Inspection results must be submitted on this;form.Inspection forms may not be altered in any
way.,T Please,see completeness checklist-at the end,of.the form.
Important:When A. General Inform, ation
filling out forms
on the computer,
use-orgy the tab 1 Inspector:
keyto'move your 0
,cursor--do not Michael Kellett
use thereturn
Name of Inspector
key:
Aardvark Environmental Inspections,
Company Name
r
P0 box,896
Com pany Address C:)
rn
'East Dennis MA .0111 4,1
Cilyfrown state Zip Code:
508-385-7608 S13742
Telephone Number Ucense'Number
B. Certification
I certify that 1,have personally inspected,the sewage disposal'system;at this address and,that the
information.reported below GIs 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 MAN).The system:
Z Passes El Conditionally Passes El Fails
'
El NeedsFurtherEva' 'luation by the Local Approving Authority
_03K9/12'
Inspector's Signature Date
The system inspector shall submit a copy of this inspection:report tathet Approving Authority(Board
of Health or'DEP)within 30,days of completing`axis inspectionAfthe system is a shared system or
has a,design-,,flow of`,10,000,gpd or greater,the inspectorand the systernowner shall submit the
report to the appropriate regional office lofthe 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:wilt perform in the future under
I the same or different conditions of ruse.
vU� � 1
IT
t5ins-11110 Title 5 Official Inspection Form:S . Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts.
Title 5 Officia I I on Form
, t nspecti
Subsurface Sewage Disposal System form Notfor Voluntary Assessments
79 1"'Avenue
Property Address
Stephen.Corrid'an
Owner Owner's Name
information is.
required for every Vilest Hyannisport MA 02672 03117/12
page. City/Town State Zip,Code Date of Inspection
B. Certification (cont.)
Inspection Summary:,Check. A,B,G,D or E always complete all of Section,D!
A) System;Passes:
I have not-found;any information which indicates that any ofthe failure criteria described
in 310 CVIR 1,5.303torin'310 CMR,15.304 exist.Any failure criteria not evaluated are
indicated below.
Comments:
B) System Conditionally Passes::
El one or more system components as described yin the"Conditional Pass'section need to be
replaced orrepaired.The system.,,upon completion of the replacement or repair,ir,as approved by
the Board of Health,will.pass.
Check the box for"yes","W 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"orthe septic tank(whether metal or not)is structurally
unsound,exhibits substantial infiltration,ortexfiltration ortank failure is imminent.System will pass
inspection if the existing tank pis 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,notleaking,and:if,a Certificate of
Compliance indicating that the tank is less than 20 years old:is available.
El Y f❑-7, N [I ND(Explain below):
t5ins-11/10 Title 501ficial Inspection Form:Subsufface Sewage Disposal System-Page 2 of 17
<f\ Commonwealth,of Massachusetts,
Ri EMEI�11 0 Title 5 Offlo"Ciall Inspection Form
101
Subsurface SewaqeDisposal System Form-.Not for Voluntary Assessments
797t"Avenue
Property Address
Stephen.Corridan
Owner Owner's Name
information is
required for every West Hyannisport MA 02672 03/17/12
page. ICityf!rown State Zip Code Date of inspection
B. C Irt",e, Wication -(cont.)
% System>Conditionally Passes,(cont.)::
El Observation of sewage backup or break-out or high state 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,(withapproval of Board of Health):
E] broken pipe(s)are replaced E] Y [] N E] ND.-(Explain below):
El obstruction:is removed [I. Y El R F_I. ND(Explain,below):
El distribution..box is leveled.or replaced El Y El N El ND(Explain below)-
El The system required pumping more than 4 times year due to broken or obstructed pipets).The
system will;pass inspection;if.(with approval of the Board of flealth):
n 'broken pipe(s)are replaced :[I Y El N n ND(Explain below):
❑ obstruction is removed Y [I U El ND(Explain.below):
C) Further Evaluation is Requiredt by the Board of,Heafth,::
F1 Conditions exist which Tequirefurtherevaluation by the.Board,of Health in order to determine it
the system is failing to:protect,public:,health,,safetyor the,environment.
1. System will pass unless lBoard of Mealth determines in accordance with 310 CMR
15.303(1-)(b)that the system is not functioning in:a:manner which wilt protect public health,
safety and the environment-.
El Cesspool or privy is within,50 feet of a surface water
'El Cesspool orprivy is within 50-feet ofabordering vegetated wetland or a salt marsh
t5ins-11/10 Title 5,0ftialInspectlonForm:Subsurface Sewage Disposal System-Page 3 of 17
Commonweaftft of Massachusetts-
Title 6, Of icial' Inspection Form.
'Subsurface Sewage Disposal System.Form Notfor VoluntaryAssessments
797"'Avenue
Property Address
Stephen Corridan
Owner Owner's Name
information is
required for every West Hyannisport, MA 02672 03117/12'
page. City/Town state Zip Code Date of nspection
B. Certification (cont.)
2. System.wilffait unless,the Board,of Health (and Public Water Supplier,if any)
determines that the system is functioning t in-a-manner that protects the,public health,
safety,and.environment:.
El The system has a septic tahkand soil absorption system(SAS)and the SAS is within
100 feet of asurface water supply or tributary to surface water supply.
[I The system has septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
El 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 privatewater,supply well".
Method used todetermine distance:
This system passes if the well.,water analysis,performed at'a DER 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 l Applicable,to All,Systems::
You must indicate"Yes"or"No!'to,each:of the following;for all inspections:
Yes No
E] S Backup of sewage iinto facility or system component due to overloaded or
clogged SAS.or,cesspool
El 0 Discharge or ponding,of effluent to the surface ofthe 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 V below invertor available volume is less
than%day flow
t5ins-11/10 Title 15 Official Inspectionform:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth:of Massachusetts
l Title 5 Official Inspection Form
U, 'Subsurface Sewage Disposal System!,Form-,Not for VoluntaryAssessments
797"'Avenue
Property Address
Stephen Gorridan
Owner Owner's: ame
information is
WeStrHyannisport MA 02672 03/17/12,
required for every ....... .....
page. City/Town State Zip Code Date of Inspection
B. -Certification (cont.)
Yes No Required pumping more.than 4times-in the lastyear NOT'due to clogged or
El 0 obstructed pipe(s).Number of times pumped:
El .0 Any'rportion 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 surfacewater supply.
El Z Any portion of&cesspool,or privy is within a Zone.I of a public well:
El Z Any portion of a cesspool or privy is within 50 feet of a private;water supply well.
El Z Any portionof 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
Jaboratory,for fecal coliform bacteria indicates absent and:the presence
of ammonia nitrogen and nitrate nitrogen,is equal to or less than 6 ppm,
provided:that no otherfailure.criteria are triggered..A copy of.the analysis
and,chain,of custody must.be attached,to this,fdrmj=
E] 0 The system.is a cesspool serving a facility,with a design flow of 2000gpd-
I 0,:000gpd.
E] Z The system fails.khave determined that one or more of the above failure
criteria e)dst as described in 310 CMR 15.303,therefore the system fads.The
system:owner should.contact the Board,of Healft to determine:what will be
necessary to,correct the,failure.
E) Large Systems: To be-cons'idemda,large system the system must serve a facility with a
design flow of 10;000;gpd to 15,000gpd.
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
1-1 El thesystem js within 400feetof a surface drinking water supply
El El the system is within L2:00 feetof a tributary to a surface drinking water supply
D El the System is located;in a nitrogen-sensitive area,(Interim Wellhead Pfolection
Area—IWPA),or a mapped Zone I[of a public.water supply well
If you have answered"yes"to,any question in:Section E the.system,is,considered a signifidant threat,
or answered"Ves"lin Section'D above the large system has failed.The owner or operator of any large
system considered,a significantthreat.under Section,E or failed under Section Dshall upgrade the
system inaccordance witli'310 CMR 15.304.The system owner should contact the appropriate
-regional office of the Department.
t5ins-11/10 Title 5 Official Inspection Form:SubsuftmSewagerDisposa[Systern Page,5 of 17
Commonwealth of Massachusetts
,
Titlb, 5 Offi cial, I'nspect ion Form
Subsurface,Sewage Disposal'S em- orm-'Notfor Voluntary Arssesshients
,yst F
797t",Avenue
Property' ddress
Stephen Corridan
Owner Owner's Name
information is
required for every West Hyannisport MA 02672 03/1,71112
page- City/Town State Zip Code Date of Inspection
C. Chedkfist
Check if the following.have.been done.You must indicate."yes"or"no7 ass to.reach of the following:
Yes No
',Pumping tinformation was provided by the owner, occupant,or Board of Health
El .0 Were'any of the system components;pumped out in the previous two weeks?
JZ El Has the system received,normal,flows.in,.the previous two4week period?
0 ER Have large volumes of water been introduced to the system recently or as part of
this inspection?
N E] Were,as built plans of the system obtained and examined?(if they were not
available note as N/A)
0 0 Was-the facility or dwelling inspected forsigns ofsewage back up?
Z (I Was the site inspected for signs of break out?,
Z El 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?
Z El Was the facility owner(and.occupants if different from,owner):provided with
information,on,the:proper maintenance:of subsurface sewagedisplasal systems?
The size and,location of,the Soil,Absorption System,(4ASI on the site has
been determined based on:
Existin'Onformation.For-example,a Plan at theBoard of Health.
Determinedin the field (if any of the fafflure criteria related to Part C is at issue
approximation of distance is unacceptable),[310 CMR't 5.302(5)];
D. System Information
Residential'Flow,'Conditions:
Number of bedrooms(design):. 3 Number of bedrooms(actual): 3
1
DESIGN,flow based on 340 CMR 15.203,(for example: 11D gpd x#of bedrooms),: 330
t5ins-11110 Tltlei5,01ficlal Inspection Form:-SubsurfaceSewage Disposal System-Page 6 of 17
Commonwealth;of Massachusetts
Tit e 5 Mi 'I Inspection Form
Subsurface Sewage Disposal Systems Form Not.forVoluntaryAssessments
i
w 79 7"Avenue
Property Address
Stephen Corridan
Owner Owner's.Name
information is required for every West Hy p annis ort MA 02672 03/17/12.
page. City/Town State :Zip Code Date of Inspection
D. 'System Information
Description:
Number of current residents:
0
Does residence have a,garbage grinder? ❑ Yes: 0 No
Is laundry on a separate sewage:system?[if yes separate inspection required],: ❑ Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonaiuse? ❑ Yes ® No
Water meter readings,,if,available(last.2 years:.usage(gpd)):
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy 09/11
:
Date:
Commem-iaUlndustria:l Flow�Conditio.ns:
Type of Establishment:
Design flow(based on 340 CMR'15.203): Gallons per day(gpd)
Basis of design.flow(seats/persons/sqA, etc:.):
Grease trap present? ❑ Yes ❑ No'
Industrial waste holdingtank:.present? ❑ Yes ❑ No
Non-sanitary waste discharged to the.Title 5 system? ❑ Yes ❑ No
Water meter readings,if available:
t5ins 11/10 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
79 7"Avenue
Property Address
Stephen Corridan;
Owner Owner's Name
information is West H annis ort MA 02672 03/17/12
required for every y p
page. Gity/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:
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)
❑ lnnovativel.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 VA system by system,operator under_contract
❑ Tight tank..Attach a copy of the DEP'approval.
❑ Other(describe):
t5ins-11/10 Tape 5 Official,Inspection Form:Subsurface 5ewage',Dlsposal System Page 8 of 17
1
Commonwealth.of Massachusetts
. .Title 6 Official Inspect1.01n Form,
Su.bsurface Sewage:Disposal'Systemfoxn-Not for Voluntary-Assessments
79 7"',Avenue
Property Address
Stephen Corridan
Owner Owner's Name
information is
required for every West.Hyannisport MA .02672 03117/12
page- City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components,,date,installed(if,known)and.source of information,:,
06t25/98 per BOH
Were sewage odors,detected when arriving at the Site? El Yes ED No
Building Sewer i(locate on site plan):
Depth below grade: 3.3
feet
Material of construction.
El cast iron -JR 40 PVC :Fl other!(ex plain):
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)-
2.5
Depth below grade: feet
Material of zonstruction:
Z concrete El metal fiberglass polyethylene n 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.:, 1,500 gal
Sludge depth: 3"
t5ins•11/10 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
<L',\ Commonwealth:of Massachusetts
a Tifte 6 Offid I InSpection Form'.
Sufturface Sewage Disposa'I'System forTn-.Not for VoluntaryAssessments
79 7�Avenue
'Property Address
Stephen Corndan
Owner Owner's Name
information is
required for every West Hyannisport MA 02672 03117/12
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
"
Distance from top of sludge to bottomof outlet tee or baffle 27
Scum thickness 2"
Distance from top-of scum:to top of;outlet tee orbaffle
Distance from bottom of scum to,bottom!of outlet tee or baffle 16"
How were dimensions determined? measured:
Comments,(onpurnoing recommendations.,inlet-andoutlet tee-or baffle condition,structural integrity,
liquid levels asTelated.to,outlet invert,-evidence ofleakage,,etc.):
The tank was sound and-tightwithtees in place and.liquid at outlet invert.
Grease Trap(locate,on site,plan)-.
Depth below grade: feet
Material of construction:
[I concrete F1 metal, E-1 fiberglass ❑polyethylene other(explain):
Dimensions:
Scum thickness
Distance from top of scum,to top of outlettee or.baffi&
Distance from bottom of scum to bottom,of outlet tee or baffle.
Date:of last,pumping: Date
t5ins•11/10 Title Official Inspection Form:Subsurface"Sewage Disposal System-Page 10 of 17
Commonwealth of Massach-usefts
Title 5 Official; Inspection Form
Subsurface Sewage Dis,posaISystemFdnn-.Notfor VoluntaryAssessments
79 7"'Avenue
'Property Address
Stephen,Corridan,
Owner Owner's Name
information is
required for every Westilyannisport, MA 02672. 03117/12
page. Cityrrown 'State Zip Code Date of Inspection
'D.. "System Information (cont.)
'Comments(on pump ingrecommendations;'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 [I fiberglass ❑ polyethylene El other(explain):
Dimensions:
Capacity: gallons
Design Flow: gallons per day
Alarm present El: Yes El No
Alarm level: Alarm in-working order: ❑ Yes ❑ No
Date of lastpumping: Date
Comments(condition of alarm and;float'switches,etc.)::
Attach copy of current pumping;contract.(required). Is,copy attached?* El Yes El No
t5ins-11/10 Title 5 Official Inspection Form:Subsurface Sewage Ojsposa[System-Page 11 of 17
<C\ Commonwealth,of Massachusetts
title-.5 Official Inspection. Form
o Subsurface Sewage Disposal System iForm,-,Not for Voluntary' Assessments
79
Property Address
Stephen Corridan
Owner Owner's Name
information is
required for every West Hyannispont MA 02672 03/.1._71,1_2'
City/Town page. '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. even
Comments{noteif box lis'level,and,distr.ibution to outlets equal,any evidence of solids carryover,any
evidence ofleakage into or out of box,etc.):
The box was level and tight with no sign of carryover.
Pump Chamber(locate on;site,plan):.
Pumps in working order: El Yes n No
Alarms in working order: R Yes El 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:
t5ins•11/10 Tide 5 Official Inspection Form:Subsurface Sawage,13isposal System,-Page 12 of 17
r
Commonwealth of Massachusetts
Title 5 Official Inspection Form;
Su,bsu:rface Sewage Disposal'System lco:rm.-,Not for Volunta.ry.Assessments
79 7"Avenue
Property.Address
Stephen Corridan
Owner Owner's Name
information is required for every West Hy p: annis,ort MA 02672 03/17/12
page. City/Town State Zip Code Date of inspection
D,. Systern Information (cont.)
Type:
❑ ^ leaching pits number:
® Teaching chambers number: 4
❑ leaching galleries number:
❑ leaching trenches number,length:
❑ leaching fields number,dimensions:.
❑ overflow cesspool number:
❑ innovative/altemative system
Type/name of technology:
Comments(note condition of soil,signs of hydraulic failure, level,of ponding,,damp soil,condition of
vegetation,etc.).-
This system has fouriinfiltrato;rs iin_a 1 VxW field of stone.There was no sign of:ponding or failure in
the stones.
Cesspools(cesspool must be ipumped as part of,inspection)(locate on site plan):
Number and configurations
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-11/10 TdIe.5 Of rialinspecliomForm:'Subsurface Sewage'Disposal'System,•'Page 13 of 17
<C\ Commonwealth:of Massachuseft
Title 5 Official Inspection Form
is, Subsurface Sewage Disposal System,Form,-:Not for Voluntary: ssessments
79 7t"Avenue
,Property Address
Stephen Corridan
Owner Owner's Name
information is West.Hyannisport. MA 02672 03/17/12,
required for every tityffown State Zip Zip Code
page- 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 pondingi,condition of vegetation,
etc.):
t5ins-11110 Title 5,0fficial Inspection Form:Subsurface 2SewagwDlsposal System-Page 14 of 17
Commonweafth of Maw achuseft
- Tuatle 5 Official Inspection Form
Subsueface Sewage Disposa I Systems Form-Not for Voluntary.Assessments
79 7t'Avenge
Property Address
Stephen Corridan
Owner Owners Name
Information is West H.annis ort MA 02672 03117H2
required for every
page tlty7Towrt State Zip Code Date of Inspection
0. System Infoati n (cons.)
Sketch Of Sewage Disposi J System:Provide a view of the+sewage disposal system,includin ties to
at least two permanent.re cence landmarks or benchmarks.Locate ag wells within 100 feet. ocate
where public water supply nters the budding.Check one of the boxes below:
hand-sketch:in the are I below
El drawing attached sepa mately
�a
t5[ns•11/10 TM9 5 0ftddat Inspection Forth:Sutsuftm-9ewags 0*0sat System•PoSe 15 of 17
Commonwealth.of, Massachusetts.
Title 5 Official- Inspection Form
sl Subsurface Sewage DisposalSystem:Form-:Not for Voluntary:Assessments
79 7m Avenue
Property Address
Stephen Corrdan
Owner Owner's Name
information is required for every y p West H, annis ort MA 02672' 03/1'7/fZ
page. City/Town State p Zi Code Date of inspection
D,. System Information (cont.)
Site Exam:
® Check Slope
❑ Surface water
® Check cellar
❑ Shallowwells
Estimated depth to high;ground water:
feet
Please indicate all:methods used'to determine'the high:ground'water elevation:
® Obta:ined;from system-design,plans on record
If checked,date of design plan reviewed:. 06/22/98'
Date
❑ Observed'site(abutking property/observation hole,within 150 feet of SAS)
❑ checked with;local+Board'of`Health-explain:
❑ Checkedd with.local excavators,installers--(attach documentation)
❑ Accessed USGS database explain::
You must describe how you established the high ground water elevation:
Before filing this lns,pection Report,;please see Report Completeness(Checklist on next page.
t5ins•11/10 Tltie 5 official Inspection�Foim:,Subsuriace'SewageDisposal System•Page 16 of 17
•
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Fonn-Not for Voluntary Assessments
7971'Avenue
Property Address
Stephen Corridan
Owner Owner's Name,
information is
required for every West Hyannis port MA 02672 03/17/12
page. VtyfTown state Zip Code Date of Inspection
E. Report Completeness CheMist
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-11110 Title-5 5 Official Inspection Form:Subsurface SLvvags:0isposalISystsm-Page.17'af 17
TOWN OF BARNSTABLE Y
LOCATION IS Se y YN S,� SEWAGE # 76
VILLAGES c�trwV�1S din Y4 ASSESSOR'S MAP & LOT
INSTALLER'S NAME&PHONE NO. �"V�e
SEPTIC TANK CAPACITY
LEACHING FACILITY: (type) g (size) �0 K •t� `l
NO. OF BEDROOMS `
BUILDER OR OWNER cO ;
PERMITDATE: . 66 A 2 2—< i COMPLIANCE DATE:1
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or widhin 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility)" Feet
Furnished by
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I����I'�'is� .5
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No. '^' Fee r
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
01ppYtcation for Mtgpogar *pgtem CowAruction Permit
Application for a Permit to Construct( )Repair( )Upgrade(P Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No.Z 6t Owner's Name,Address and Tel.No.
Assessor's Map/Parcelu��er/'
511A
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
�IY1`i0-L�r Seel a�
�U V4 2--'(c-
Type of Building:
Dwelling No.of Bedrooms_ Lot Size sq. ft. Garbage Grinder( )
Other Type of Building No.of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow gallons per day. Calculated daily flow gallons.
'Plan Date Number of sheets Revision Date
Title
Size of Septic Tank l"-j�' db�no M _k/ Type of S.A.S. t Cc,
Description of Soil
Nature of Repairs or Alterations(Answer when a plicable) 5 � S I C. `���— _6 L
t c on Q o.TO N
k Q
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 t to place the system in operation until a Certifi-
cate of Compliance has been is s B
Signed Date 16_ L
Application Approved by r - e Date �Z ~
Application Disapproved for the folio ing reasons
Permit No. 7 Date Issued w—2 z '9
9 .No. 37 F �,
Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in compute
Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE., MASSACHUSETTS
Zipprication for ;Digpogal *pgtem (Congtruction i3ermit
Application for a<Permit to Construct( )Repair( )Upgrade(C)Abandon( ) ❑Complete System ❑Individual Components
Location Address or Lot No'7 1R �jev�y�l �a�.� Owner's Name,Address and Tel.No.
Assessor'sMap/Pazcel _ Y--(—Utio�t/'
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
' r
S.
W z�Y C /
Type of Building:
'+_.,,,Dwelling No. of Bedrooms _ Lot Size sq.ft. Garbage Grinder( )
Other Type of Building No. of Persons Showers( ) Cafeteria( )
Other Fixtures
Design Flow �� gallons per day. Calculated daily flow -34 gallons.
Plan Date Number of sheets Revision Date
Title
Size of Septic Tank db 5)ok�nt4-i Type of S.A.S. V, Cc, C
Description of Soil
►, Nature of Repairs or Alterations(Answer when applicable) 150V
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 't to place the-system in operation until a Certifi-
cate of Compliance has been issuQdllyjhis Bo -
Signed Date 10 V
Application Approved by Date -2 2-
Application Disapproved for the folio ing reasons
Permit No. `,� — 3 7 , Date Issued d-<?Z 1.0
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
(Certificate of (Compliance
.-THIS IS TO CERTIFY, that the On-site Sewage Disposal System Constructed ( )Repaired ( )Upgraded(X)
Abandoned( )by V,-\1
at e.:rs.r�-� wa ovr" has been constructed in accordy
with the provisions of Title 5 and the for Disposal System Construction Permit No. 9 '3"7 1( dated 6 '- 7- 7 -9 Y
Installer Designer
The issuance of this permit shall not be construed as a guarantee that the syst m will function as designed.
Date Inspector
No. 9 r-3 76 -------------Fee sr)-
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLE., MASSACHUSETTS
MiOogal *pgtem CowAruction permit
Permission is hereby granted to Construct( )Repair( )Upgrade(y)Abandon( )
System located at -7 ct $ J-c zc- Pt<
and as described in the above Application for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided:Construction must be completed within three years of the date of 7All-
A
Date: 6- 7 2 `-g_ Approved by_ ,
10/9/97
NOTICE: This Form Is To Be Used For the Repair Of Failed
Septic Systems Only.
CERTIFICATION OF SKETCH AND APPLICATION FOR A
DISPOSAL WORKS CONSTRUCTION PERMIT (WITHOUT
ENGINEERED PLANS)
hereby certify that the application for disposal works
construction permit signed by me dated Q2—�`��`�� , concerning the
property located at 2 S� N, t meets all of the
following criteria:
V• There are no wetlands located within 100 feet of the proposed leaching facility
P P g
v There are no private wells within 150 feet of the proposed septic system
ere is no increase in flow and/or change in use proposed
• There are no variances requested or needed.
4 If the proposed leaching facility will be located within 250 feet of any wetlands,the bottom of the
proposed leaching facility will not be located less than fourteen(14)feet above the maximum adjusted
groundwater table elevation.
Please complete the following:
A)Top of Ground Elevation(according to the Engineering Division G.I.S.map) N-1155
B)Observed Groundwater Table Elevation(according to Health Division well map) c C)
SIGNED: DATE:
LICENSED SEPT SYSTEM INSTALLER IN THE TOWN OF BARNSTABLE NUMBER
I ,
[Attach a sketch plan of the proposed system.Also if the licensed installer posesses a certified plot plan,
this plan should be submitted].
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T��O``W��N OF BARNSTABLE
LOCATION �� S� �7�'� 1(�-� SEWAGE # 7
VILLAGE '� cti y<�4l�i;S Vila�(�t ASSESSOR'S MAP & LOT r
INSTALLER'S NAME&PHONE N0. �r-Y �i�e ✓- Ian,�•- (titer n
SEPTIC TANK CAPACITY
LEACHING FACELrrY: (type) C,Jk-i t (size)
NO. OF BEDROOMS
BUILDER OR OWNER
PERMIT DATE: 10/-2 2 di COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility (If any wetlands exist
within 300 feet of leaching facility) Feet
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