HomeMy WebLinkAbout0121 STERLING ROAD - Health It 21 sterling load
Hyannis
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TOWN OF BARNSTABLE L�
LOCATION aZ I 57L�'n Q N G (Z. SEWAGE #
VILLAGE ASSESSOR'S MAP &LOT A267 )9?"
4 INSTALLER'S NAME&PHONE NO. -V N K"O L,y Q
SEPTIC TANK CAPACITY /®c2c>
LEACHING FACILITY: (type) P(q (size)
NO.OF BEDROOMS 3
BUILDER OR OWNER L D2 CrL� (o A
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
Furnished by
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LOCATION SEWAGE PERMIT 110.
VILLAGE
I N S T A LLER'S NA-ME i ADDRESS
i UIL,DE R OR OWNER `
OA T E P E R M I T I S S U E D
D-ATE COMPLIANCE ISSUED
w
0 z
GA
ALA_
THE COMMONWEALTH OF MASSACHUSETTS
BOAR® OF HEALTH
.................................----.....OF.............................---.......------------------------------------------------...
Apfiratiun for Di,spuii al Worko Tons rur#iun runfit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at: 66 3
:. .!� - •---•------------•-----------------•-• ----.....---•--------------------------------- �-------•-------------------------------
�^ � Location-Add _or Lot No.
.... �.1+/\/.1...'^ ......••.. --•..................................... .......... •-•-•---•------.............---•--------••----•_.
Owner Address
W .........
Installer Address
Type of Building Size Lot............................Sq. feet
V Dwelling—No. of Bedrooms.....3....................................Expansion Attic ( ) Garbage Grinder ( )
aOther—Type of Building ............................ No. of persons.....----.................. Showers ( ) — Cafeteria ( )
Q' Other fixtures -------------------•••••......-- ---
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
WSeptic Tank—Liquid capacity............gallons Length................ Width..;...........-- Diameter.-------.------. Depth................
x Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.-----_----.------. Depth below inlet.....--............. Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................................
aTest Pit No. 1................minutes per inch Depth of Test Pit.................... Depth to ground water.---.---.----.-......---
(� Test Pit No. 2................minutes per inch Depth of Test Pit...--............... Depth to ground water......--................
----------------------------------•--------------------••--•--------------------•------......---•--..............:..........................................
0 Description of Soil.................................................................................'
x
V ---------•-••----•-------•-•--•--------------------•-----------------•-------...---•---......---.--------.... ----------------------------
•----•----------------------------- -----------
W ----••------------------------------------------------•------------•-----•--------•----•--- ...... ................... ............. ------.... -----•-••-
UNature of Repairs or�A�ratio —Answer when pl e--- -
Agr eement:
The undersigned agrees to install the afor escribed Individual ewage Disposal System in accordance with
the provisions of AI'I iZ- 5 of the State Sanitary Code—The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued by the board of health.
Sign ---• ........................
ApplicationApproved B •---------•----------------------------------------------------•- ....'-.. -�•--------------------
Date
Application Disappr ed or t following reasons---------------------------------------------------------------------- ---------------------------------------•-
-•-•••--••--•-•••••••--•••-•-••••----•-•••• ---------------------------------------------------- ....--•-----------------------------------------------------------------------
Date
PermitNo.................................................••••.... Issued........................................................
Date
1...... Fms...,o...................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
...--•-. .... .. ............O F............................................----------------..............----------------
Applira#ion for Uiipns al Worka Tomitrnrtion Prrmit
Application is hereby made for a Permit to Construct ( ) or Repair ( ) an Individual Sewage Disposal
System at:
.�............................................ ....................•••--•----------•----_.. ...------.._._......_...I...--•----•----•--
- Location-Addr _••-'------••--•---------------^---•-••--or Lot No.
.�+. .. -----• •-------••------••---•------•----•----- -----•-•-'..........................................
Own
{� er ------------------------------Address
Installer Address
Type of Building Size Lot............................Sq. feet
U Dwelling—No. of Bedrooms___.,, ....................... .....Expansion Attic ( ) Garbage Grinder ( )
'4 Other—T e of Building No. of persons............................ Showers — Cafeteria
p, Other fixtures -----•......--••--•--•---•--•---
W Design Flow............................................gallons per person per day. Total daily flow............................................gallons.
0. Septic Tank—Liquid capacity............gallons Length-------------_ Width................ Diameter................ Depth................
Disposal Trench—No. .................... Width.................... Total Length.................... Total leaching area....................sq. ft.
Seepage Pit No--------------------- Diameter.................... Depth below inlet.................... Total leaching area..................sq. ft.
Z Other Distribution box ( ) Dosing tank ( )
Percolation Test Results Performed by.......................................................................... Date........................:...............
aTest Pit No. 1----------------minutes per inch Depth of Test Pit.................... Depth to ground water--___----_-__-_--_-_-._.
Test Pit No. 2................minutes per inch Depth of Test Pit.................... Depth to ground water........................
--------•----------------------------•----------------------------..............._....------•---•---.........................................................
0 Description of Soil........................................................................•-••-----------------------------------••- ----------------------------------------------------
x
V
W -----•••-•-------------------•-•----••-------------------•----------•---•--•------•••-•---------------------. ' ---I-•--
Natureo Repairs or 1 atio —Answer when a li ble.____
U PP '�'�. ._ V rye,...
Agreement: v
The undersigned agrees to install the afore scribed In ividual Sewage Disposal System in accordance with
the provisions of TITif- 5 of the State Sanitary Code— The undersigned further agrees not to place the system in
operation until a Certificate of Compliance has been issued byUhebbord of health.
ifs
Signed/ _
Y .._..Nli
._
r
Application Approved By....z Wiz- .:.-zl� _..:
-----......-•---•-••-•--•----•--••----•--------•--....------ -------- -•••••-••-•--- -----•---------
Date
Application Disappro ed r111 ,ollowing reasons:_..---•------------------------------------------------•---------------------------------------------.........--
-----------------•----------••-•- . --•-------•-•--------•--------------------•-.--...-------------•-------•.---------••-..................------........•---- .------•-----.
Date
PermitNo......................................................... Issued.......................................................
Date
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HEALTH
ram . :. .
Tnrtifirate of TuntpliFanrr
IS I TO RTI Y That the Individual Sewage Disposal System constructed ( ) or Repaired ( '
- A `
q............. ;-.=. '----------..........---•-•---•--------.....--- ---------------••--•--•------------.....................-•-•---••-•-------•--••-•---------
f __.__..__.__
nstaller
`� as been installed in accordance with the provisi is f TITLE 5 of T/he State Sanitary Cod asXscribed in the
application for Disposal Works Construction Pe ' No...... _�.'._Z_2, e....__...._. dated-... .�_I'___ ___4...................
f
THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE
SYSTEM WILL FUNCTION SATISFACTORY.
DATE...............................................S..�.1.:66...•---- Inspectoy:.... . 11!: -...............................................
THE COMMONWEALTH OF MASSACHUSETTS
BOARD OF HE LT
OF
No......................... Y FEE- �-----......-----
-Disp aa1 , 1 �_ n uan rrani� `
� .Permission is hereby grad, •-------�----- --..�...--�- -.........-.........................................................................
to Construct ( )L r R aim ( _an divi ual Sewa Disposal System
/StreetCIA
�
as shown on the app ti� Disposal Works Construction P�fnut No.. .__.�� __ Dated.....�`.�1..'_ ._ '�__._....
i s• l
.•• -
P Board of Health
f t Gs
DATE........ .-r--------•---•--------------------•-•----•------- �'°
FORM 1255 HOBBS & WARREN. INC., PUBLISHERS
s OA a5_.
COMMONWEALTH OF MASSACHUSETTS /o 7
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
-DEPARTMENT OF ENVIRONMENTAL PROTECTION
,. r
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR.VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM `
PART A
CERTIFICATION
Property Address:
Owner's Name:
Owner's Address: a G`V
~ ( � C
pDate of Inspectioncri $- ,?D.-®7 -- - - _ � -_�`J`"` -- �P
Name of Inspector: (please print)
Company Name: J-04,1 /V41-t Boeo v'e-
. Mailing Address: I$2 wl, ,,
/1//s�rs ohs il/J.� s �q v�2(y.1f C)
Telephone Number: ' ,50f-412 F-7779
CERTIFICATION STATEMENT
M
I certify that I have personally inspected the sewage disposal system at this address and that the info ation 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 SSecti6n 15.340 of Title 5(310 CMR 15.000).. The system: '
• t // Passes
Conditionally Passes
"'. Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: 4��Y/G 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.
t
Notes and Comments
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of l l
OFFICIAL INSPECTION FORM—]NOT-
SUBSURFACE R
SEWAGE DLSPOS 'VOLiI1�FI'AR `
��y,A
INSPECTION FORM :;•�;: .,, •
PART A
CERTIFICATION(oomtinued)
Property Address: %2! S�r/iH �j �p ':; • .
Owner. ®, y 7 ,
, y!
Date of Inspection: 2 -20
- p�
Inspection Summary: Check A,B,C,D or E/ WAY_fi completi-jlt atioa.D
A• System Passes:
have not found any information which indicates
15.303 Orin 310 CMR 15.304 exist.Aby failure that any of the failure criteria described in 310 CMR
criteria not evaluated are indicated below.
Comments:
B. System Conditionally passes:
One or more system components as described in the"Conditional pass"
repaired.The system,upon completion of the seetion need to be replaced or
replacement or repair,as approved by the Board of Health,will pass. .
Answer yes,no or not determined(y,N,ND in the
explain. ) for the following statements.
. g If `not determined please
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurall
unsound,exhibits substantial inf ltration or exfiltradon or tank y
existing tarok i replaced with a complying septic tank as �� imminent.System will pass lespec7ion if the
*A metal septic tank will pass inspection if it is structuralpmved by the Board of Health.
indicating that the tank is less than 20 y S°�.not leaking and if a Certificate of Compliance.
Years old is available.
ND explain:
Observation of sewage backup or break-out or high Obstructed pipe(s)or due to a broken, static water level in the distribution box due to broken or
approval of Board of Health): settled or uneven distribution box Sys will pan inspection if(with
broken pipes)am
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken of obstructed pipe(s).The system will
pass inspection if(with approval of the Board of Health):
broken pipes)are replaced
Obstruction is removed
ND explain:
s
'Page 3ofII
OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE"DISPOSAL:SYSTEM INSPECTION FORM ,
PART '
CERTIFICATION;(continued)
Property Address: 1:21 51 r11h 7� ou
Gh�/1
Owner. (vci-oz / ev,
Date of Inspectio : Y,--10—O
C. Further Evaluation is Required by the Board of Health: >-
Conditions exist which require ftuther 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 -
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'l00 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'l of public-water supply.
e. '9 i Y
" 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 frond a
private water supply well**.Method used to determine distance r
**This system passes if the well water analysis,performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form. 71.
3. Other:
3
Page 4 of 11 w
OFFICIAL INSPECTION FORM—NQTtXOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISP0 :INS N,FOR ,
PART_A ,•
CERTIFICATI0Kj
Property Address: /2J bpl
Owner:_ OO 24
Date of Inspec n:_ Sf—lO—o7
D System Failure Criteria applicable to all systems:.
You most indicate Y'�•"yes"or"no"to each of the following for aH iim� •- -
Yes No
— v Backup of sewage into facih'ty or system component due to overloaded or clog
ged SAS or cesspool
V 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 distriibndou box above oudet.invert due to an overloaded or clogged SAS or
cesspool
t/ Liquid depth in cesspool is less than G'below invert or available volume is less am✓:day flow
_,_,_ v Required pumping mom than 4 times in the last year NQ_Tdue to clogged or obstructed pipe(s).Number
of times pumped
_j L 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.
J/ Any portion ofa 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 than30 feet'i namprivate water
supply well with no acceptable water quality analysis,(This system passes if fte4ve8,ayater analysis,
Performed at a DEP certified laboratory,for conform bacteria and volatile organic compounds
indicates that tbfe well Is tree from poltntiou from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 Ppm,provided that no other failwe criteria
are triggered.A copy of the analysis must be attached to this form
(Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as
described in 310 CMR 15.303,therefore the system fads.The system owner should contact the Board of
Health to determine what will be-necessary tam the failure.
L Large Systems:'
To be considered a large tem the
gp� rg sys system must same a beiliti►with a design flow of 18,000 gpd to 15,000
You must indicate either"yes"or"no"to each of thfoltowing:
(The following criteria apply to large systems in addtion to the criteria Ann)
yes no
— — the system is within 400 feet of a surface drinking water supply
— the system is within 200 feet ofa tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(bw im Wellhead Protection Area—IWPA)or a mapped
Zone U of a public water supply well lr•
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 operation 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.
4
Page 5 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL.SYSTEMINSPECTION FORM
y 0. PART B
'.CHECKLIST
r A i
Property Address:
Owner: edr [A
Date of Inspe lon: 3'—2 O—O 7
Check if the following have been done.You must indicate`yes"or"no"as to each of the following:
Yes No
✓ — Pumping information was provided by the owner,occupant,or Board of Health
— Were any of the system components pumped out in the previous two weeks?
_: Has the system received normal flows in the previous two week period?
Have large volumes of water been introduced to the system recently or as part of this inspection?
t/- Were as built plans of the system obtained and examined?(If they were not availables note.as N/A)
f/ — Was the facility or dwelling inspected for signs of sewage backup?
Was the site inspected for signs of break out?
✓— Were all system components,excluding the SAS,located on site? '
[/_ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition
of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum?
(/ Was the facility owner(and occupants if different from owner)provided with information on the proper
maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption,System JSAS)on the site has been determined based-on:
Yes no
— ✓ Existing information.For example,a plan at the Board of Health.
— Determined in the field(if any of the failure criteria related to Part C is at issue.approximation of distance
is unacceptable)(310 CMR 15.302(3)(b)J "
5
Page 6 of 11
OFFICIAL.INSPECTION FORM-NOTFOROTNTAVY ASSESSMEh'3'S .
SUBSURFACE SEWAGE DISPOW.SYS MM INSPECTION FORM
PART C
SYST-WINFORMATION
Property Address: A21 5 rf rfi h 9494J
hh/s tS - -
Owner: -r.eo vw,m
Date of I=Pecd6w. B —20-07 -
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design). 3 Number of bedrooms(actual): _
DESIGN flow based on 310 CMR 15.203(for example:110 gpd x#-of bedrooms):
Number of curz=t residents:
Does residence have a garbage grinder(yes or no):�c
Is laundry on a separate sewage system Lyes or nod A/a[if yes separate,inspection required]
Laundry system inspected(yes or nor
Seasonal use:(yes or no);�s
Water meter readings,if available(last 2 usage(S�)� 1:2/pc' It,5t 2 Pur s
Y�
Sump pump(yes or no): �t/v
Last date"ofoccupancy, r�1�v4ry s)We
COMMERCIALANDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): aad
Basis of design now(seats/p=ons/sq%ctc.)•
Grease trap present(yes or no):
Industrial waste holding tank present(yes or no):_
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occuimcyluse•
OTHER(describe): -
GENERAL INFORMATION
Pumping Records
Source of information: y w h-e e
Was system pumped as part of the inspection(yes or no):
If yes,volume pumped:.igallons--How was quantity pumped determined?
Reason for pumping: -
TYPE OF SYSTEM
1/Septic tank,distribution box,soSabsorption syshm
_Single Cewool
—Overflow cesspool
_ivy
_Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative tedmology.Attw�i a cagy of thec==operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
_Other(describe):
Approximate age of all components,date installed(if lmown)and source of information:
37 -Pal-s
Were sewage odors detected when arriving at the site(yes or no):/f/o
6
Page 7 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
P PART C -
' " -SYSTEM INFORMATION(continued)
Property Address: ,,/
Owner: evr o"O&A
Date of Inspec on: Y—zv —D7
BUILDING SEWER(locate on site plan) _ U
L�
Depth below grade:.
Materials of construction: cast iron 40 PVC other(explain):
Distance from private water sup ply well or on line: '
Comments(on condition of joints,venting,evidence of leakage,etc.):
SEPTIC TANK:_(locate on site plan)
Depth below grade: 2 y ,
Material of construction: concrete_metal_fiberglass_polyethylene
_other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of .
-
Dimensions:
Sludge depth: 2 "
Distance from top of sludge to bottom of outlet tee or baffle:
Scum thickness: O
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle: . r.
' How were dimensions determined: 1jgeA>c,v ins )gad
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of.leakage,etc.):
4,— �'�e pNd ouft�fi coH� to �h ymvc� cap,at, 1" �I-
s?NrtG , !,37// S lfG VAS/ '
r
GREASE TRAP:_(locate on site plan)
Depth below grade:
Material of construction:_concrete_metal_fiberglass_polyethylene_other
(explain):
Dimensions
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity, liquid levels
as related to outlet invert,evidence of leakage,etc.):
7
Page 8 of l i
-OFFICIAL-INSPECTION F0RM:.;44ItY ;'- ?QR=T A SESSMENTS
SUBSURFACE SEWAGE DISPQ ,S^Y$TEM FORK-
rAft-C. . - �:.
SYSTEM INFORNrAnON(con med)
Property Address: 121 Jrrr4 4 )Foa6
Owner:
Date of n: S::2O-v
TIGHT or HOLDING TANK; (tank must be pDmped at time of tusiteplan)
plan)
Depth below grade:
Material of construction: metal fiberglass_polyethylene- pther(explain):
-_
Dimensions:
capacity gallons -
Design Flow: aallans/day
Alarm present(yes or nor
Alarm level: Alarm in working order{yes or nor-
Date of last pumping:
Comments(condition of alarm and goat switches.etc.):
DISTRIBUTION BOX: Cif present must be openedj(locate og site plan)
Depth of liquid level above outlet invert:
Comments(note if box is level and distrrbntioa-to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.):
—9aY,
PUMP CHAMBER: (locate on site plan) _
Pumps m workimg order(yes or.no):
Alarms in working order(yes or no):
Comments(note condition of pomp chamber, Ikiiiefpmps aad finances,prH):. .: .
Page 9 of l l
OFFICIAL.INSPECTION.FORM.-NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE;DISPOSAL SYSTEM INSPECTION FORM
PART C.'
SYSTEM INFORMATION(continued)
Property Address: oa�(
Owner. Qvr
Date of Inspec n: — O—0 7
SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not required) "
If SAS not located lain wh -exp Y• ..
TT 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.):
�— y�. :�Qa��e .�i}�s wi��. s�H.v��tk, no � �uio� .oti T�►.P�-r
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 or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction: '
Dimensions• ,
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
9
Page l0 of I l
OFFICI LINSPFZnON FORM NO FOlt�'V'l3LU1�TT Y��
SO�tSURFACE.SEWAGE DYSPOSAi SY$'FEM SON FORM '
• SYSTEM DMRNIAnON(cowwu4
- .. AO .t ... .
2/ �TrI�K
Property Address:
Owner.
• Dateorbspemow._ �'��'�/c .�i: �:a •f;4 t.i�- •nt + :+'-4.ii i=. .i i✓s +
SKETCH OF SEWAGE DISPOSAL SYSTEM _ ...
Provide a sketch of the sewage disposal system bdu&g ties-t0 at hest two pes =09 reference landmarks or
bencbmadm Locate aII Welk wtd"100_feet.Ike wherrpublic water supply enters the buildbig.
Y l 0
�I
1
Csp
h
7�l' O� T„1•s�,
O 6 � To t?.Strs
Page l l of I l
y
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE.S*WAGE DISPOSAL SYSTEM INSPECTION FORM a
PART C
SYSTEM INFORMATION(continued)
Property Address: /a/ Star h"'% �Gad
Owner: ea ..t fee /.dror
Date of Inspec on: 8—?0—D 7
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water ,45 S. feet
Please indicate(check)all methods used to determine the high ground water elevation:
Obtained from system design plans on record-If checked,date of design plan reviewed:
Observed site(abutting property/observation hole within 150 feet of SAS)
Checked with local Board of Health-explain:
Checked with local excavators,installers-(attach documentation)
Accessed USGS database-explain:
You must describe how you a t#blished the h,i�h ground water elevation,,:� ,
p Q H�' ,5l av'r f,t;
Alftlev t9 N Gk d ri O
S `f S. Lt//i i G 1' ..$� � �..Q? .tlu r 1 1 S � •[!/e1/�
11
Town of Barnstable
�p 1HE 1p�
Regulatory Services
rrsrnsLE Thomas F. Geiler, Director
9$ 6 9. ••� Public Health Division
Thomas McKean, Director
200 Main Street, Hyannis, MA 02601
Office: 508-862-4644 Fax: 508-790-6304
This septic system inspection report was completed by a private inspector who is certified
by the State of Massachusetts, Department of Environmental Protection.
Although the Town of Barnstable Health Division received the original/copy of this
report; this Division does not warranty the functionality of the septic system in the future
nor does this Division agree with any technical observation s and interpretations
contained within this report.
In addition,by receiving this report the Town of Barnstable Health Division does not
automatically approve the number of bedrooms listed within this report. The actual
number of bedrooms approved at a particular property would-be listed on the "Disposal
Work Construction Permit".
If you should have any questions regarding this report, please contact the certified Septic
System Inspector who conducted the inspection.
TOWN OF BARNSTABLE i
LOCATION _�aZ �S12LING 2 SEWAGE # '
VILLAGE NYIAJ�h1? ASSESSOR'S MAP&LOT 19T
INSTALLER'S NAME&PHONE NO. uN!IL OW
SEPTIC TANK CAPACITY 10a;lcO
i
LEACHING FACILITY: (type)
(size)
NO.OF BEDROOMS
BUILDER OR OWNER G&=_0
PERMITDATE: COMPLIANCE DATE:
Separation Distance Between the:
Maximum Adjusted Groundwater Table and Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility.(If any wetlands exist
within 300 feet of leaching facility) Feet f
Furnished by
I
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5 3�i iI
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