HomeMy WebLinkAbout0036 SIMMONS POND CIRCLE - Health 36 SIMMON'S POND CIRCLE,HYANNIS
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Hyannis, ZIP 02601 $ 006.480
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0001383424 JUN. 08. 2015.
Y7014 1200 0001 0358 3933 - ------ - — - -
Marcia Stockwell
36 Simmons Pond Circle
Hyannis, MA 02601 -_
N1XIE, 015 DE- 1009 Goa6'/1,.5 /15
RETURN TO .SENDER
NOT DELIVERABLE AS ADDRESSED 9
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■ Complete items 1,2,and 3.Also complete A. Signature
item 4 if Restricted Delivery is desired. [3 Agent 1
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■ Print your name and address on the reverse Addressee I
I so that you.we can return the card to Y B. Received by(Printed Name) C. Date of Delivery I
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
D. Is delivery address different from item 1? ❑Yes
1. Article Addressed to: If YES,enter delivery address below: 0 No
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Marcia-Stockwell
i 36 Simmons .Pond Circle 3, Service Type
1 .H, yan T :MA 02601 O Certified Mail® 0 Priority Mail Express"'
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"— - ❑Insured Mail ❑Collect on Delivery
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2. Article Number
(Transfer from service labeo ,7 014 1200 001 0358 3 9 3 3
} g PS Form 381.1,:July:2013 Domestic Return Receipt
- ;� Barnstable
Regulatory Services Department A P
D
i ,19•A� Public Health Division m
fp" 200 Main Street, Hyannis MA 02601 2007 .
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL # 7014 1200 0001 0358 3933
June 3, 2015
Marcia Stockwell
36 Simmons Pond Circle
Hyannis, MA 02601
ORDER TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 36 Simmons Pond Circle, Hyannis, MA was last
inspected on 514/2015, by Michael DiBuono, a certified septic inspector for the
State of Massachusetts.
The inspection of the septic system showed that the system "Conditionally
Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the
following:
• Distribution Box is deteriorated.
You are ordered to repair or replace the septic system components within one
(1) year from the date you receive this notification by replacing the distribution
box and replacing the failed leaching pit.
Failure to repair/replace the septic system within the deadline period will result in
future enforcement action.
PER ORDER OF THE BOARD OF HEALTH
a cKean, R.S., CHO
Agent of the Board of Health
Q:\SEPTIC\Conditionally Passes Ltr\36 Simmons Pond HY Jun 3025.doc
TOWN=SEWAGE'#
LOCATION
VILL&GE ASSESSOR' MAP & LO
D14 FCroRs`NAME&PHONE NO.
SEPTIC TANK CAPACITY D 71
LEACHING FACILITY: (type) ,/} ��� (size) 1000 .
NO.OF BEDRO
BUILDER O OWNE
PERMITDATE: 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
Furnished by
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o Marcia Stockwell
36 Simmons Pond Circle ---
Hyannis, MA 02601
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Certified Mail Provides,,_ T
o A mailing receipt
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o A record of delivery kept by the Postal Service for two years
Important Reminders:'
n Certified Mail may ONLY be combined with First-Class Mail®or Priority Mails.
o Certified Mail is not available for any class of international mail.
o NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
•valuables,please consider Insured or Registered Mail.
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delivery.To obtain Return Receipt service,please complete and attach a Return
Receipt(PS Form 3811)to the article and add applicable postage to cover the
fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for
a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is
required.
o For an additional fee; delivery may be restricted to the addressee or
addressee's authorized agent.Advise the clerk or mark the mailpiece with the
endorsement"Restricted Delivery".
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receipt is not needed,detach and affix label with postage and mail: _
IMPORTANT-Save this receipt and present it when making an inquiry:'
PS Form 3800,August 2006(Reverse)PSN 7530-02-000-9047 f- J
Barnstable
Regulatory Services Department
�ST"M I
9 Public Health Division
200 Main Street, Hyannis MA 02601 2007
Office: 508-862-4644 Richard V.Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
CERTIFIED MAIL# 7014 1200 0001 0358 3933
June 3, 2015
Marcia Stockwell
36 Simmons Pond Circle
Hyannis, MA 02601 ,
ORDER-TO COMPLY WITH STATE ENVIRONMENTAL CODE, TITLE 5
The septic system located at 36 Simmons Pond Circle, Hyannis, MA was last
inspected on 5/412015, by Michael DiBuono, a certified septic inspector for the
State of Massachusetts.
The inspection of the septic system showed that the system "Conditionally
Passes" under the guidelines of 1995 TITLE 5 (310 CMR 15.00) due to the
following:
• Distribution Box is deteriorated.
You are ordered to repair or replace the septic system components within one
(1) year from the date you receive this notification by replacing the distribution
box and replacing the failed leaching pit.
Failure to repair/replace the septic system within the deadline period will result in
future enforcement action.
PER ORDER OF THE BOARD OF HEALTH
a cKean, R.S., CHO
Agent of the Board of Health
C _1
° -2..
OCII
Q:\SEPTIC\Conditionally Passes Ltr\36 Simmons Pond HY Jun 3025.doc (��
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Town of Barnstable
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i67q. Regulatory Services Department
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AjfD MA'S#
Public Health Division
200 Main Street, Hyannis MA 02601
Office: 508-862-4644 Richard Scali,Director
FAX: 508-790-6304 Thomas A.McKean,CHO
Feb 6, 2007
Rev. 4/28/15
DEADLINES TO REPAIR FAILED SYSTEMS
(Town Code §360-44 and Title V: 310 CMR 15.000)
An"x"marked in the ❑ is the failure criteria and associated repair deadline
60 DAY DEADLINE CRITERIA
❑ Discharge or ponding of effluent to the surface of the ground
❑ Pumping more than 4 times during the last year not due to clogged or obstructed
pipe
❑ Backup of sewage into the house due to an overloaded or clogged SAS or cesspool
ONE (1) YEAR DEADLINE CRITERIA
❑ Static liquid level in the distribution box above outlet invert due to an overloaded or
clogged SAS or cesspool-
❑ Any portion of the SAS, cesspool, or privy below high groundwater elevation
❑ Any portion of the cesspool within a Zone 1 to a public well
❑ Any portion of a cesspool within 50 feet of a private water supply well with no
acceptable water quality analysis. (This system passes if.the water analysis
indicates the well is free from pollution).
TWO (2) YEAR DEADLINE CRITERIA
❑ Single Cesspool a
❑ Any"conditionally passed systems" (broken cover, relocation of a pipe, relocation
of a driveway due to H-10 components, etc)
❑ Leaching pit or cesspool with high liquid level, <1.2" below pit(per Town Code
§360-9.1)
OTHER
Repair deadline:e
Q:\SEPTIC\DEADLINES TO REPAIR FAILED SYSTEMS.doc
Commonwealth of Massachusetts
W Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 Simmons Pond Cir
Property Address
Marcia Stockwell .
Owner Owner's Name
information is Hyannis MA Q2601 5/4/15
required for every — _
page. City/Town V 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 A. General Information
filling out forms
on the computer, ��
use only the tab 1 Inspector:
key to move your
cursor-do not Michael DiBuono
use the return -- —
Name of Inspector,:
key. .,
DiBuono"Sewer-arid Drain
ea Company Name , —
8 Johns path
Company Address
S Yarmouth MA t - 02664
City/Town -- _ State. Zip Code
508-364-9587_______ S113522
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
5_�_ 5%5/1
stfi pector'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.
Lt5ins13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
.'' 36 Simmons Pond Cir
Property Address
Marcia Stockwell
Owner Owner's Name
information is required for every Hyannis MA 02601 5/4/15
page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:'
❑ i have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The system contains a 1,000 gallon tank as well as a concrete Distribution box. All tees and baffles
are in place. The Distribution box is rotted and in need of replacement. The leaching is made up of a
single 1,000 gallon leach pit. staining inside leach pit indicates the level has been to within 20 inches
of invert pipe but now holds little water.
�i
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):
15ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 36 Simmons Pond Cir
Property Address
Marcia Stockwell _
Owner Owner's Name
information is required for every Hyannis MA 02601 5/4/15
_
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):
System passes as long as Dbox is replaced.
❑ 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
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 Simmons Pond Cir
Property Address
Marcia Stockwell
Owner Owner's Name
information is required for every Hyannis MA 02601 5/4/15
—�—
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 1/2 day flow
t5ins•3113 - Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°°�M e,•'' 36 Simmons Pond Cir
Property Address
Marcia Stockwell
Owner Owner's Name
information is required for every Hyannis MA 02601 5/4/15
_
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 II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 Simmons Pond Cir
Property Address
Marcia Stockwell
Owner Owner's Name
information is required for every Hyannis MA 02601 5/4/15
_
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?
El ❑ 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?
El ❑ Were as built plans of the system obtained and examined? (If they were riot
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
El ❑ Was the site inspected for signs of break out?
❑ Were all system components, excluding the SAS, located on site?
El ❑ 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.
El ❑ 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
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
a,••' 36 Simmons Pond Cir
Property Address
Marcia Stockwell
Owner Owner's Name
information is H required for every annis MA 02601 5/4/15
_Y
page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
The system contains a 1,000 gallon tank as well as a concrete Distribution box. All tees and baffles
are in place. The Distribution box is rotted and in need of replacement. The leaching is made up of a
single 1,000 gallon leach pit. staining inside leach pit indicates the level has been to within 20 inches
of invert pipe but now holds little water.
Number of current residents:
2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? (Include laundry system inspection El Yes ® No
information in this report.)
Laundry system inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available (last 2 years usage (gpd)): 24.5 gpd
Detail:
2013: 9,200 gal 2014: 8,600 gal
Sump pump? ® Yes ® No
Last date of occupancy: OccupiedDate
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
Title 5 official Inspection Fora
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
0�.
36 Simmons Pond Cir
Property Address
Marcia Stockwell
Owner Owner's Name
information is required for every Hyannis MA 02601 5/4/15
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: —
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):
15ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
N Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 Simmons Pond Cir
Property Address
Marcia Stockwell _
Owner Owner's Name
information is required for every Hyannis MA 02601 5/4/15
—�—
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:
29 Years
Were sewage odors detected when arriving at the site? Yes ❑ No
Building Sewer(locate on site plan):
Depth below grade: 18 "sfeet
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.):
System is vented throught the roof.
Septic Tank (locate on site plan):
Depth below grade: 1 ftfeet
Material of construction:
® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain)
1,000 gallon
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1000 Gallon ----
Sludge depth:
3"s
l5ins-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 36 Simmons Pond Cir
Property Address
Marcia Stockwell
Owner Owner's Name
information is required for every Hyannis MA 02601 5/4/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cost.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle 24"s
Scum thickness 3"s
Distance from top of scum to top of outlet tee or baffle 47's
Distance from bottom of scum to bottom of outlet tee or baffle "Sludge stick
How were dimensions determined? Tape Measure
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Recommend pumping at this time.
Grease Trap (locate on site plan):
Depth below grade: NA
reef
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
za Title 5 Official Inspection Fora
Subsurface Sewage [disposal System Form - Not for Voluntary Assessments
36 Simmons Pond Cir
Property Address
Marcia Stockwell
Owner Owner's Name
information is
required for every Hyannis MA 02601 5/4/15
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.):
No evidence of leaking. Pumping is recommended
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•3113 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
36 Simmons Pond Cir
Property Address
Marcia Stockwell 1.
Owner Owner's Name
information is required for every Hyannis MA 02601 5/4/15
_
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 Needs to be replaced
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.):
Distribution Box is in need of replacement
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:
l5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
4� Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 Simmons Pond Cir
Property Address
Marcia Stockwell _
Owner Owner's Name
information is y required for every _Hyannis MA_ 026p1 5/4/15
page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
�f leaching pits number:
❑ leaching chambers number: --
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions: —
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology: --
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
No signs of carry over. no signs of hydrualic failure
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
l5ins•3113 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
36 Simmons Pond Cir
Property Address
Marcia Stockwell
Owner Owner's Name
information is required for every Hyannis MA 02601 5/4/15
—�— —
page. City/Town State Zip Cede Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
No signs of ponding or hydruulic failure.
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 TitIEl! 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
\M a 36 Simmons Pond Cir
Property Address
Marcia Stockwell
Owner Owner's Name
information is y required for every _H annis MA 02601 5/4/15
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
t51ns•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
_..._. i
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I I' vql
'Sullsu UfA, ' ' I►'M IN`�t' ',C''I'IU.f"J FOW
A 10
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SKETCIIOF'.S, RYA �;DISh'4SA,L,SY�`�'EW "'�
I� '. r
nclu�lt ties to atlleaast two r� 1aj1e11t-,ic(cic11ce&,',Inii�l��istrks;ar.l�ew�c,l� ,
. i
n�flrk�,
Loc;ateA wells*1thilt-100'Fcet
17
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, I
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}!DEPTH TO GROUNDWATER* �
Depth to groundwater _ � / Feel ` �H{,{
I 4 t f1 1 aIn ut,
Method of Deternunation to pP
�f r ximatio��;
7.
y 5
1 ��rlL/�� lid I col 114 —
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�c 36 Simmons Pond Cir
Property Address
Marcia Stockwell
Owner Owner's Name
information is Hyannis MA 02601 5/4/15
required for every _Y _ _
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: 20+ ft
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: pate
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked'with local Board of Health -explain:
❑ Checked with local excavators, installers- (attach documentation)
® Accessed USGS database -explain:
usgs ma_�
You must describe how you established the high ground water elevation:
Property sits 20 ft above nearest water venue. According to usgs maps system is approximately 20.+
ft above ground water.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
15ins•3/13 Title 5 Official Inspection Form:'Subsurface.Sewage Disposal System•Page 16 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
e
36 Simmons Pond Cir
Property Address
Marcia Stockwell
Owner Owner's Name
information is H annis MA 02601 5/4/15 _
required for every _Y
page. City/Town State Zip Code Date of Inspection
E. Report Completeness Checklist
❑ Inspection Summary: A, B, C, D, or E checked
❑ Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
❑ System Information-- Estimated depth to high groundwater
❑ Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
F No. e�L� t 6 7 Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer: /
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS Yes
ZippliLation for Disposal 6pstem Construction Permit
Application for a Permit t Construct( ) Repair W11 Upgrade( ) Abandon( ) ❑Complete System Individual Components
N
Location Address or Lot No. s6 s(mA'mons T_Ard.;C I P, Owner's Name,Addres ,and Tel.No. ?13-S f/-2 a
NIQrYaea. S t.c.�L l A.6 nax � }
Assessor's Map/Parcel 2sq /.,)/
I taller' Name d s,and Tel.No �- �� Designer's Name,Address,and Tel.No.
I)rpe 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(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) _ -
Date last inspected:
Agreement:
The undersigned agrees to ensure the construction and maq*at ce of the afore described on-site sewage disposal system in
accordance with the provisions of Title 5 of the Environmental Code an not to place the system in operation until a Certificate of
Compliance has been issued by this Board of He t1l.
Signed - - Date �(�
Application Approved by Date
Application Disapproved by Date
for the following reasons
Permit No. ��C Date Issued /
!!!`
s a
f•
No. e�1 ( � ' �) Fee
.. THE.COMMONWEALTH OF MASSACHUSETTS Entered in computer..
�J
e Yes
PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLE, MASSACHUSETTS
Nplication--for -Misposaf 6psteut Construction 3permit
Application for a Permit to Construct( ) Repair( Upgrade( ) Abandon( ) ❑Complete System Individual Components
Location Address or Lot No. .3&S(M mOns 1_o► Owner's Name,Address,and Tel.No. ?13..,.6-YQ -- ?OSL.
Mar6o S�c-kwet t 4,0. Sax 7s
Assessorr's p/Parcel a� /.j/ NLIar/)i S 0641 n
i
I stalller' N 4ddr ss andkT4No ,, - �/�g— Designer's Name,Address,and Tel.No.
5.i'tf' OY
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(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)
Date last inspected:
Agreement:
a The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system in
r ` accordance with the provisions of Title 5 of the Enviro erfmode not to place the system in operation until a Certificate of
Compliance has been issued by this Board of H
ealth.
Signed / _. Date � �� ,
Application Approved by A Date
-
Application Disapproved by '`- Date
for the following reasons
Permit No. J-V Date Issued
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE,MASSACHUSETTS
Certificate of Compliance
THIS IS TO CERTIFY,/that
�-the On-site Sewage Disposal system Constructed( ) Repaired( Upgraded( )
Abandoned( )by1' ICx1,C ( ?�/ict��Y 01'1� �_,►'�C
has been constructed in accordance
with the provisions of Title 5 And the for Disposal S em Construction Permit No v( -(� dated S b?
P + P Y ��
Installer t'to Ens�- F (_C�'l, -.OC Designer /
#bedrooms ��" Approved design flow / gpd
The issuance of thislylf
rm't/shall not be construed as a guarantee that the system will` n- • design .
Date lt� Inspector �^ df ef
------------------------------------------------------------------------------------------------------------------------/----------------
No.c)V I "' � Fee I� -
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION- BARNSTABLE,MASSACHUSETTS
Misposal &pstem Construction 'Permit
Permission is hereby granted to Construct( ) air 4�L ) ( ) ( )
System located at t 5 P Abandon
10epl) C/I"C�I Upgrade !'� i/ n n
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.
4: Provided:Construction must be completed within three years of the date of this permit. L
Date 7 Approved by
YOU.WISH TO OPEN A BUSINESS?
For Your Information: Business Certificates cost $40.00 for 4 years. A Business Certificate ONLY REGISTERS THE BUSINESS NAME in
town (which you must do by M.G.L.- it does not give you permission to-operate.) You must first obtain the necessary signatures
on this form at 200 Main St., Hyannis. Take the completed form to the Town Clerk's Office, 1st FL., 367 Main Street, Hyannis, MA
02601 (Town Hall) and get the Business Certificate that is required by law.
Fill in please: Date: 1 Z as 17'
t
APPLICANT'S NAME: (-GAN K Writ.
YOUR HOME ADDRESS: 5'jd'�M(�t.11 �bal G i�Lt^L NN.ln) 1s
11YAt Is ft Al OLb u ']
BUSINESS TELEPHONE # HOME TELELPHONE #:
EIN ORS N: zi 15 1961 0
NAME OF CORPORATION: kllyt FID #
NAME OF NEW BUSINESS
..TYPE OF BUSINESS ctJ)Ll�,
IS THIS A HOME OCCUPATION? YES X NO
ADDRESS OF BUSINESS MAP/PARCEL NUMBER (Assessing).
When starting anew business there are several things you must do to be incompliance with the rules and regulations of the Town
of Barnstable. This form is to assist you in obtaining the information you may need. You MUST GO TO 200 Main St. (corner of
Yarmouth Rd. R Main Street) to make sure you have the appropriate permits and licenses required to legally operate your
business in town.
1. -BUILDING COMMISSIONER'S OFFICE
This individual has been informed of any permit requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
2. BOARD OF HEALTH
This individual has bepp4nformed of the permit requirements that pertain to this type of business.
Authorized Signature**
COMMENTS:
3. CONSUMER AFFAIRS (LICENSING AUTHORITY)
This individual ha ee of med of the licen 'n requirements that ertain t this type of business.
Authorized Signature** C S~�-it✓ L L)
I
/(� To Z w or
p 199 �
- - BORTOLOTTI CONSTRUCTION, INC. 1 %/
765 WAKEBY ROAD,MARSTONS MILLS, MA 02648
508-771-9399 508-428-8926 FAX: 508428-9399 ®j 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address:
Date of Inspection: / Inspector's Name:
n@r's Name d Address:
CERTIFICATION STATEMENT*
I certify that I have personally inspected the sewage disposal system at this address and that the informa-
tion reported below is true,accurate and complete as of the time of inspection. The inspection was per-
formed based on my training and experience in the proper function and runintenance of on-site sewage
disposal stems. The System:
Passes
Conditionally Passe
Needs Further Ev tion Local Aproving Authority
Fails
Inspector's Signature: Date: Q
The System Inspector all submi a copy of this inspection report to the Approving authority within thir-
ty(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 owner
and copies sent to the buyer, if applicable and the approving authority.
INSPECTION S IMMARY•
A)SYSTF,IGI 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.
B)SYSTEM CONDITIONALLY PASSES;
One or more system components need to be replaced or repaired. The system,upon comple-
tion of the replacement or repair, passes inspection.
- Indicate yes, nor,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,cracked,structurally unsound,shows substantial infiltration or
exfiltration,or tank failure is imminent. The system will pass inspection if the existing sep-
tic tank is replaced with a conforming septic tank as approved by The Board of Health.
Sewage backkup 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):
- 1 -
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
' PART A
CERTIFICATION (continued)
Broken pipes)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. A `
C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by The Board of Health in order to determine if
the system is failing to protect 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:
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.
.2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER
SUPPLIER,IF APPROPRIATE)DETERMINES THAT THE SYSTEM IS FUNCTION-
ING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
The system has a septic tank and soil absorption system and 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 is with a Zone I of a public
water supply well.
The system has a septic tank and soil absorption system and is within 50 Feet of a private
water supply well.
The system has a septic tank and soil absorption system and 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
the facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less
than 5 ppm.
D)SYSTEM FAELS:
I have determined that the system violates one or more of the following failure criteria as defined
in 310 CMR 15.303. The basis for this determination is identified below. The.Board of Health
should be contacted to determine what will be necessary to correct the failure.
Backup of sewage into facility or system component due to an overloaded or clogged SAS
or cesspool.
Discharge or ponding of efluent 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 clog-
ged SAS or cesspool.
Liquid depth in cesspool is less than 6"below invert 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
-2- ,
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A '
CERTIFICATION (continued)
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 no acceptable water quality analysis. If the well has been analyzed
to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic
compounds,ammonia nitrogen and nitrate nitrogen.
E)LARGE SYSTEM FAILS:
The following criteria apply to a large system in addition to the criteria above:
The design flow of a system is 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:.
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
QWPA)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 program requirements of 314 CMR 5.00 and 6.00. Please consult the local
regional office of the Department for further information.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CIIECKLIS'1'
Check if the following have been done: . '
✓Pumping information was requested of the owner,occupant,and Board of Health.
None of the system components have been pumped for atleast 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.
_,,6s-built plans have been obtained and examined. Note if they are not available with N/A.
. ISThe 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,excluding the Soil Absorption System, have been located on site.
J✓The septic tank manholes were uncovered,opened;and the interior of the septic tank was in-
► i e liquid,
spected for condition of baffles or tees,material of copstruction,dimensions,ors,depth th of q uid,
depth of sludge,depth of scum.
, The size and location of the Soil Absorption System on the site has been determined based on
existing information or approximated by non-intrusive methods.
-3-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST(continued)
1/ The facility owner(and occupants,if different from owner)were provided with information on
the proper maintenance of Subsurface Disposal System
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
FLOW CONDITIONS
RESM1FNTIA1.-!
Design Flow: rP-Zs,jf
lions Number of Bedrooms: 3 Nun bcr of Current Residents: o2
Garbage Grinder: Laundry Connected To System:. Seasonal Use:�<)
Water Meter Rea ailable:
Last Date of Occupancy:
�OM1VtFRCLAI JINDUSTRrAL: A_)j
Type of Establishment:
Design Flow: gallons/day Grease Trap Present: (yes or no)
Industrial Waste Holding Tank Present:
Non-Sanitary Waste Discharged To The Title V System:
Water Meter Readings,If Available: Last Date of Occupancy:
OTHER: Describe)
Last Date of Occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System Pumped as part of inspection:_ If yes,volume umped: 61 gallons
Reason for pumping:
TYI OF SYSTEM:
Septic Tank/Distribution Box/Soil Absorption System
Single Cesspool
Overflow Cesspool
Privy
Shared System(If yes,attach previous inspection records, if any)
Other(explain):
AP ROXIMAT AGE of all components,date installed(if known)and source of information:
Sewage odors det ted when arrivin&qat the site:
-4-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C .
GENERAL INFORMATION (continued)
SEPTIC TANK:
Depth below grader Material of Constnuction: Pco"ncrete metal---- RP_Other
(explain)
Dimisions: Sludge Depth: Scum Thickness: &
Distance from top of sludge to bottom of outlet tee or baffle: y "
Distance from bottom of scum to bottom of outlet tee or baffle: Z
Comments: (recommendation for pumping,condition of inlet and outlet tees or baffles,depth of liquid
level in relation t outlet invert, structural integrity evidence of leak e. etc)ILQZ.01 6041
GREASE TRAP:
Depth Below Grade: Material of Construction: concrete metal FRP Other
(explain) — _ _ _
Dimensions: Scum'Thickness:
Distance from top of scum to top of outlet tee or baffle:
Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles,depth of liquid
level in relation to outlet invert,.stnictural in(egri(y, evidence of leakage..etc.)
TIGHT OR HOLDING TANK:/)d
Depth Below Grade: Material of Construction:,concrete_metal_FRP_Other(explain)
Dimensions: Capacitv:_ gallons Design Floc: gallons/day
Alarm Level:
Comments: (condition of inlet tee, condition of alarm and float switches, etc.)"
DISTRIBUTION BOX:
Depth of liquid level above outlet invert:4
Comments: (note if I el and disttibution is equal, evi ence of solids carryover, evidence of)eakage into
or out o box,etc.)
. PUMP CIL& IBER:A) _
._Pump is in working order:
Comments: (note condition of pur►ip chainber,condition of pumps and appurtenances,etc.)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SOIL ABSORPTION SYSTEM(SAS):_
(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:
Comments: (note condition of soil, igns of hydraulic failure I vel of pond' ,condition of vegetation, i
etc. -
CESSPOOLS:A-b
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(cesspool must be pumped as part of inspection)
Comments:.(note condition of soilk, signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)
PRIVY:
Materials of construction: Dimensions:
Depth of Solids:
Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation,
etc.)_
-6-
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
SKETCH OF SEWAGE DISPOSAL SYSTEM: ,
Include ties to atleast two permanent references, landmarks or benchmarks.
Locate all wells within 100 Feet.
o2 70 "
3a �
y7,
DEPTH TO GROUNDWATER:
Depth to groundwater: 9 Feet
Method of Determination or A imation:
Y�4DS•
-7-
AF�-1
LaC
A T ION SEWAGE PERMIT NO.
Ott I-U T le,
VILLAGE
Z411�
INSTALLER'S NAME & ADDRESS
0 U I L D E R OR OWNER
DATE PERMIT ISSUED 9114AY
DATE COMPLIANCE ISSUED /� ��
W
o0
O v
1
V.i
w -
N
t
1
No.....Rel- / FRs..... d..................
THE COMMONWEALTH OF MASSACHUSETTS
'ARD OF HEALTH
." ............ J.................OF............. ..... ....................................................
Appliration for Uiipnsal Works Tonstrnrtinn amit
Application is hereby made for a Permit to Construct ( ) or pair ( ) an Individual Se age Disposal
System at:
.............. - •-- ......................................... ems¢ _.:.- ..........`..�.�'�- ..................---••-
Location-Address r or Lot No.
. :..� .........1•-•-• .6�5..._ d..e .................................................................................................
caner /� Address
�` �j� �Jtrr
/ ..................
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms..............�.--.--_.-. -___-_--Expansion Attic ( ) Garbage Grinder ( )
Other—Type of Building ............................ No. of persons............................ Showers — Cafeteria
Q, Other fixtures -------------------------------- ---..
WDesign Flow............................................gallons per person per day. Total daily flow__._...... ..?o...................gallons.
WSeptic Tank—Liquid capacity/1CC.).riallons Length................ Width................ Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area..__'T_w.0---sq. ft.
Seepage Pit No------_------------- Diameter.................... Depth below inlet.................... Total leaching area...............;..sq. ft.
Z Other Distribution box ( ) Dosing tank ( ) r i
'� Percolation Test Results Performed by.......................... ..5......C..._......... Date....../.� �����
,aa Test Pit No. 1..... Jminutes per inch Depth of Test Pit.................... Depth to ground water........................
(i Test Pit No. 2fi minutes per inch Depth of Test Pit.................... Depth to ground water........................
0 --------------•--------------•------•--•...........--•---------------. ....--------------------...----------••------------------...---...---
Descriptionof Soil------------------------------ ---------------- ---•--... .. -•----•. -
x .............................................................. ... ....----- � .... ------........................................................................
U
W ....................-...................................................................................................................................................................................
UNature of Repairs or Alterations—Answer when applicable.._.............................................................................................
-----•-----------------------------------------------•----------------------.................---------...------------------------------------------------------......--•----------•...----•-------
Agreement: #
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLi4 5 of the State Sanitary Code—The u dersigned further agrees not to place the system in
operation until a Certificate of Compliance has been iss e bo lth.
a
Signed---• ----- ............ .... ...... ... .:....::: ....
Date
ApplicationApproved By.........-•-•--•.......... •. .................... ................................
Date
Application Disapproved for the following reasons---------------------•--•----•-------------------------••------------------------------------------........--•---
-----------------------------•-•••-•---•--•-------------•-•----•-•--••-•-----------------..........••-------•--------------------------•----------•-•---•----•--••-•-•-----•--•--•--------•-----........
Date
PermitNo.......................................................- Issued_-------------------------------------------------------
Date
No....41 f :�!-J Fss... G... ...........
THE COMMONWEALTH OF MASSACHUSETTS
,
BOARD OF HEALTH
A
...........71,f ...-...-.OF..............�.....�.......___............................................
Applira#ion for Diipnottl Workii Tonstrurtion Prrutit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at
..............••....�r�. .. ..... �°6� ' ��� ...........................................� ........ -
--
Location-Address or•Lot No.
000
............ .._._. ,,�------ -�, '- - .....� �..............•----••-•••..... -----•-••••--•-•••••.....................•..........
Owner Address
Installer Address
U Type of Building Size Lot___________________________S q. feet
1-1 Dwelling—No. of Bedrooms.............. _ -_----.--•--_--__--Expansion Attic ( ) Garbage Grinder ( )
Other a —Type of Building ---------------------------• No. of persons............................ Showers ( > — ( )Cafeteria
Otherfixtures -•-•--•----•-•---------•--••-•-•--------------•--•---.----•-••-------•-----•-•-••--•..._........._---•--•-- ---- -----•_ ------•---
W Design Flow............................................gallons per person per day. Total daily flow.___ ._..................gallons.
WSeptic Tank—Liquid capacity NA.gallons Length................ Width..............:..Diameter................ Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area._—_Z,.G..6---sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
z Other Distribution box ( ) Dosing tank
Percolation Test Results Performed by........................... _-CX.....C.................... Date... ........ _... .�
Test Pit No. 1... _ ..�_minutes per inch Depth of Test Pit.................... Depth to ground w ter_-_r____._-___-_-r.
GPI Test Pit No. 2 .. ute r inch Depth of Test Pit.................... Depth to ground water........................
.0 Description of Soil........................................ c
U --------------------------------------
•...............................° - ... - '' -------. .....................................................
U Nature of Repairs or Alterations—Answer when applicable...............................................................................................
.............................. -----------------•------------......-----•--•--------•---------•--...----.....-----------------------------.............................................................
Agreement:
The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with
the provisions of TITLE 5 of the State Sanitary Code—The undersigned further agrees not to place the syst7t in
operation until a Certificate of Compliance has been issued e board o
Signed : ..... .��� ...
ate
Application Approved By.................: -__._.. /_-
.. ......................•------- -------------------.. --•--.........
Date
Application Disapproved for the following reasons-................................................----............................................................
--•---••---------•-••--•-•---•----•••-----•••-----•-•..........................................................•-•-••-----••-•---...------......•-----•-•--•----•-......--•----•--••--• --------•--------
Date
PermitNo....................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
..........................................OF.............................................................I......................
uprrtifirab of Toutplitturr
THIS IS TO TIFY at the I dividual wage Disposals stem constructed ( ) or Repaired ( )
by------------------- ��o /... . ..........(:� �' ....�'
r Installer
has been installed in accordance with the provisions of TI;LB 5 of The State Sanitary Code as described in the
application for Disposal Works Construction Permit ................ dated..------------------------_.....................
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE..... ...... ' a ..` y Inspector.......... ......._ ••••••-••-••-•••••-•• .....-•----•----------------......................................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
No. ......................................OF....................................................................................
M,0110.6 al Via Pnigi ' n anti#
Permission is hereby granted...................................... --------------- ------------- `�,�f 1� ..................
i to Construct ( ) on Affair air ( ) an Individual Sewage Dis sal System"-,,,,!16 -�
/.
Street
as shown on the application for Disposal Works Construction Permit No.................. 1 Dated..........................................
q ._.� ....r ----- ---.--
. Board of Health
DATE.................................................................................. t jrtT
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